Application For Reimbursement Of Cost Of Spectacles
INTEGRAL COACH FACTORY, CHENNAI 600038
(for employees in service only)
APPLICATION FOR THE GRANT OF STAFF BENEFIT FUND TOWARDS THE REIMBURSEMENT OF THE COST OF SPECTACLES PURCHASED BY THE EMPLOYEE
1. Name of the applicant :
(in BLOCK letters)
2. Designation :
3. Shop/Office :
4. T.No :
5. Emp.no. :
6. Date of appointment :
7. Rate of pay on the date of application :
8. Scale of pay on the date of application :
9. Telephone no/mobile no. if any :
10 Date on which Rly hospital/ Private
hospital has given the prescription
(Enclose prescription) :
11. Actual cost of the spectacles :
(Enclose original bill) Bill no. Date:
12. Name & address of the shop where
the spectacles has been purchased :
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Declaration of the applicant
13. I hereby declare that the particulars furnished above are correct. If any of the particulars furnished above is false, I will be liable to be taken under D&A rules.
Signature
Date:
Forwarded to secretary/SBF Committee (SPO/Welfare)
Date: Signature of the Supervisory Official
Office seal:
(Certified by the ADMO/DMO/Sr/DMO/ICF hospital)
14. Certified that the above employee has procured the glasses specified for him.
Signature of the Doctor
Date:
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Note:
Eligibility: 1. Scale Rs.5500-9000 and below
1. Maximum amount reimbursable Rs.500/- or the bill
amount which ever is less.
Other requirements:
1. Original bill
2. Spectacles power certificate in original
Certification of ICF Hospital doctor on the application at Column no. 14.
