S.# No. & Date of Name of the Name of Drugs/Medicines with Amount Bill/Cash Memo Chemist Quantity/Details of Tests Rs. Shop/Hospital/Clinic/Dispensary etc. Total Amount For PITAC employee For Authorized Medical Attendant Signature ___________________________ Signature______________________ Designation__________________________ Designation____________________ Section/Shop______________________ Official Stamp________________
S.# No. & Date of Bill/Cash Memo Name of the Chemist Shop/Hospital/Clinic/Dispensary Name of Drugs/Medicines with Quantity/Details of Tests etc. Amount Rs. Total Amount For PITAC employee Signature ___________________________ Designation__________________________ Section/Shop______________________ For Authorized Medical Attendant Signature______________________ Designation____________________ Official Stamp________________