with seal and full signature) : (a) Hospital charges including diet etc. : Rs. (b) Expenses for pre and post operation Check ups:Rs. ______________ Total :Rs. I hereby declare that the particulars furnished above are correct. If any of the particulars are found to be incorrect, I realize that I will be liable action for suitable action apart from refund of financial assistance, if any received by me. Signature of the Mine/Beedi worker Place: Date: CERTIFICATE BY THE MANAGEMENT It is certified that Shri/Smt/Kum/ is employed in this ……………………………… mine/Beedi Establishment by me as ( mention designation) …………………………….. and that his/her wage is ………………………… p.m. It is certified that no wage have been paid to Shri/Smt/Kum. ……………………. for the period of his/her treatment from to …………………….. ……………………….. ……………………. His/her Identity No. is Card/‟B‟ Reg. ……………………………………….. Signature Designation Name & address of the Beedi/Mine management. Date
with seal and full signature) : (a) Hospital charges including diet etc. : Rs. (b) Expenses for pre and post operation Check ups:Rs. ______________ Total :Rs. I hereby declare that the particulars furnished above are correct. If any of the particulars are found to be incorrect, I realize that I will be liable action for suitable action apart from refund of financial assistance, if any received by me. Signature of the Mine/Beedi worker Place: Date: CERTIFICATE BY THE MANAGEMENT It is certified that Shri/Smt/Kum/ ……………………………… is employed in this mine/Beedi Establishment by me as …………………………….. ( mention designation) and that his/her wage is ………………………… p.m. It is certified that no wage have been paid to Shri/Smt/Kum. ……………………. …………………….. for the period of his/her treatment from ……………………….. to ……………………. His/her Identity Card/‟B‟ Reg. No. is ……………………………………….. Signature Designation Name & address of the Beedi/Mine management. Date
forms_no4.%20.docx