T

Health Booklet No PrD No./PPQ No.

A.M,U. Medical Attendance Scheme

G Employee's Health Form
(FOR OFFTCE RECORD)

1..

Name of the Employee/ Pensioner..

Father's / Name.,....
Husband's ................'........,.......Designation......

Date of 8irth........... ............,.,..A9e.....,.:....... ........Sex.....

Department (Present)/ At the time of retirement.

Nature of Employment: Temp. I V erm. I P r ob,/Extn./Re-emp./Other..................

LIST OF DEPENDANTS

Visible
S. No. Name Age Sex Relationship
ldentification
mark

I declare that above information is correct.

Signature & Seal of

Signature of Employee ChairmanfSection Head

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I}PLICAT'ION FOITNI A
FO& AMU MEI}ICAI., ATTENNANPE SCHEIVIE I\{F]MBERSHIP

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Office of the Director

Medical Attendance $cheme
IU.U , Aligarh

Ref. No. /MAS Dated;

Assistant Finance Officer (S'alaryl

A.M.U., Aligarh

Mr.lMrs./Ms *--lD No Workrng as

in the Departm*nt has been enrolied as menrher
of MedicalAttendance Scheme and issued heaith booklet No nn

You are requested to start necessary deduction of fvfuOlarf Attendance Scheme contrrbL,tror':
from his/her salary from the month of His/her $alary Register No. is

Director
Medical Attendance Scheme

Oftice of the Director'

Merjical Attendance Scherre
AMU,Aligarh

Ref. No. /MAS Dated

Assistant Finance Officer (Salary)

A.M.U., Aligarh

Mr.lMrs./Ms. lD No. Working as

in the Depadmenl has been enrolled as rnember
of MedicalAttendance Scheme and issued health booklet No a1n

You are requested to start neces$ary deduction of MedicalAtterrdance $cheme contribution

from his/her salary from the month of Hisiher Salary Register No is

Dinector

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