financial assistance received by me. Place : Signature of the applicant or thumb impression Date : (Name in block letters) CERTIFICATE BY THE MEDICAL OFFICER OF THE RECOGNIZED CANCER HOSPITAL Certified that Shri/Smt./Kum. who is employed as …………………………………………………… in the Mine/Beedi …………………………………………………… Establishment of has undergone treatment ……………………………… in this hospital as in-patient/out-patient for cancer with effect form ………………………………… OR Certified that Shri/Smt./Kum. ………………………………… wife/son/daughter/ father/mother of Shri/Smt./Kum. who is employed as ……………………………………… in the Mine/Beedi ……………………..……………………………… Establishment of has ……………………………………………………………… undergone treatment in this hospital as in- …………….……………………………………………… patient./ out-patient for cancer with effect from to …………………… ……………………..
financial assistance received by me. Place : Signature of the applicant or thumb impression Date : (Name in block letters) CERTIFICATE BY THE MEDICAL OFFICER OF THE RECOGNIZED CANCER HOSPITAL Certified that Shri/Smt./Kum. …………………………………………………… who is employed as …………………………………………………… in the Mine/Beedi Establishment of ……………………………… has undergone treatment in this hospital as in-patient/out-patient for cancer with effect form ………………………………… OR Certified that Shri/Smt./Kum. ………………………………… wife/son/daughter/ father/mother of Shri/Smt./Kum. ……………………………………… who is employed as ……………………..……………………………… in the Mine/Beedi Establishment of ……………………………………………………………… has undergone treatment in this …………….……………………………………………… hospital as in- patient./ out-patient for cancer with effect from …………………… to ……………………..