Ambulance Form

APPLICATION FORM FOR THE RESERVATION OF

STAFF WELFARE ORGANIZATION AMBULANCE.

 

 

1.         Name:- ____________________________________________________________________

 

2.         Designation with BPS: ________________________________________________________

 

3.         Office of Employee: __________________________________________________________

 

4.         Residential Address: __________________________________________________________

 

5.         Date: _______________ Time: ________________ Opening Meter: ___________________

 

6.         Name of Patient and Relationship _______________________________________________

            with Govt. Servant

 

7.         Purpose of Journey: __________________________________________________________

 

8.         Particulars of Journey to be performed: ___________________________________________

            ___________________________________________________________________________

            ___________________________________________________________________________

            ___________________________________________________________________________

            ___________________________________________________________________________

            I shall abide by the prescribed terms and conditions regarding the use of Staff Welfare         Organization’s Ambulance.

 

 

                                                                                    SIGNATURE OF THE APPLICANT

CHARGES:

 

1.                     FOR AMBULANCE                                                  HIRING CHARGES

 

            i)          Employees in BPS.1-10 & Dependants.                                   Rs.20/- Per Visit

           ii)          Employees in BPS.11-16 & Dependants.                                 Rs.50/- Per Visit

          iii)          Employees in BPS.17-22 & Dependants.                                 Rs.70/- Per Visit

                        In addition, waiting/detention @ Rs.30/- per hour

                        after the Ambulance reaches the Hospital shall

                        also be charged.

 

 

2.                     FOR MORTUARY VAN

 

            i)          F.G. Employees & their dependants BPS.1-16.                        Rs.06/- Per K.M.

           ii)          BPS.17-22.                                                                      Rs.08/- Per K.M.         

          iii)          Other than F.G. Employees in Autonomous,

                        Semi Autonomous & Provincial Departments.                          Rs.15/- Per K.M.

          iv)          Retired Employees & dependants of Retired/                          30 % of the charges

                        Deceased Employees.                                                        in (i) & (ii) above.

 

NOTE:

 

            i)         Only one way shall be charged.

 

FOR OFFICE USE

 

ALLOWED/NOT ALLOWED.

 

            Time _______________ Dated ________________ Closing Meter :______________

 

            Actual Meter ___________ Received Amount : ____________ Vide R/No:________

 

 

                                                                                                ( WELFARE OFFICER )

 



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Address: Staff Welfare Organization G-6, Aabpara, I   slamabad.

Phone: +92-51-9244564
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