Federal Staff Relief Fund Form

 

GOVERNMENT OF PAKISTAN

ESTABLISHMENT DIVISION

STAFF WELFARE ORGANIZATION

ADMISSION FORM FOR THE GRANT OF OUT OF FEDERAL STAFF RELIEF FUND

 

 

  1. Name of Applicant (In Bolck Letters). ________________________________________________
  2. N.I.C. No._______________________________________________________________________
  3. Designation with BPS.  ____________________________________________________________
  4. Name of Office & Address.  ________________________________________________________
  5. Length of Service.   _______________________________________________________________
  6. Purpose for which grant has been applied for
    1. Death of Govt. Servant              BS 1-22
    2. Death of Dependent                              BS 1-16
    3. General Ailment                                     BS 1-16
    4. Opticals (only for Govt Servants)           BS 1-16
  7. Name, age & relationship with Govt. servant (In case grant is required for dependent) ______       _____________________________________________________________________________________
  8. Nature Duration of Sickness. ______________________________________________________________
  9. Whether applied for the grant earlier if ‘YES’ indicate result. ______________________________________
  10. Telephone No. _____________________Office ___________________Res ________________________
  11. Residential Address.______________________________________________________________ _______________________________________________________________________________

PART B (TO BE FILLED IN BY THE D.D.O HEAD OF OFFICE)

No. _________________                                                                              Date. ____________________

Certified that the particulars mentioned under Part-A above are correct.

Signature

 

MEDICAL CERTIFICATE

I Dr._____________________of _____________________ Holding registration No._______

Of P.M.D.C. __________________ Hereby certify that Mr./Mrs./Miss./Mst.  ______________

S/o,D/o,W/o ___________________________ is suffering from _______________________

Since _____________________ and will require treatment for ________________________

He/Her case is recommended for special diet/medical treatment/surgery. The copies of the documents/schedule of treatment are enclosed.

Note:- Stemp with name of Doctor will only be accepted

 

Signature & Seal of Doctor

                         


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