WAPDA MEDICAL DIRECTORATE 2 Colored

MEDICAL REGISTRATION FORM - A Photographs

Form No. __________ New Registration Change

Version. 3 Revised On 14-10-2015

1. Company / WAPDA WING 2. Family-Id (for office use only)

4. Registration Status
3. C.N.I.C. No.
(Contract, Regular, Retired, Widow, Deputation, Out Station)
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5. Employees Name

6. BPS 7. Designation

8. Birth Date 9. Joining Date 10. Last Posting Date

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11. Fathers / Husbands Name

14. Family 15. Blood 16. Facility

12. Gender 13. Marital Status
Size Group (Facility/Cash Allowance)

17. Office Name (In case of retired or deceased employee last office Name)

18. Office Postal Address 19. Phone No. (with City code)

20. Pension Book No. 21. * Retirement Date

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22. Pension office Name

23. Pension office postal Address 24. Phone No. (with city code)

25. Home Address (Postal Address) 26. Phone No. (with city code)

27. Email Address

28. Mobile Number 29. Registration/Application Date

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Signature (MS/DMS) Employee Signature

* Date of Retirement (In case of retired employee), Date of Death (In case of Deceased employee)

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 MEDICAL REGISTRATION FORM - B
31. 32. Date of Birth /
Sr. 30. Dependants Name
Relationship C.N.I.C No.
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DECLARATION OF EMPLOYEE
1. I declare that neither my father nor my mother is a pensioner and he/she is not availing Free Medical Facilities / Cash Medical Allowance from
any other institution.
2. I declare that my wife/Husband is not availing Free Medical Facility / Cash Medical Allowance from any other Institution.
3. I declare that the family members mentioned above are wholly dependent upon me and residing with me.
4. In case of any false declaration I may be dealt under relevant rules.
Employees Signature

CERTIFICATE FROM CONCERNED OFFICE

Drawing and Disbursing Office Name and Address (Salary/Pension Drawing Office)

D&D
City: Phone
Code
Office Memo No Dated EPF NO

1. This is to certify that the particulars given in this form are correct as per office record and employees dependants information
has been verified from Form-B issued by NADRA.

Sign. & Stamp

Sign. & Stamp Drawing & Disbursing Officer
Office Accounting Head (In case of Retired / Deceased employee attestation from
Last/Retiring Office is required)

TO BE FILLED BY THE WAPDA HOSPITAL

The employee whose particulars are given in this form is hereby allowed Medical Facilities in accordance with WAPDA
Medical Attendance Rules.

Signature (MS/DMS)
WAPDA MEDICAL CARD INFORMATION
33. Card No. 34. Issued on 35. Issued by (Name & Signature) 36. Received By (Name, CNIC No & Signature)

CHECKLIST OF DOCUMENTS TO BE ATTACHED

Change of option from CMA to Medical Facility in
Attested copy of CNIC of employee and his/her dependents having
1 5 case of BPS ( 1-15 ) issued from Drawing &
age of 18 years or above.
Disbursing Officer (in original)
Attested copy of Form-B issued by NADRA / Birth certificates of all
2 6 Nikah-Nama (where applicable)
children having age of 5-years or below.
Non-marriage and non employment declaration on judicial paper
in case of cash medical allowance of a retired
3 from employee for his/her daughter having age above 25 years 7
employee his option/Application (in original)
(renewable yearly)
Attested copy of Pension Book of retired employee (family pension Female married employees submit dependency and
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book in case of deceased employee) residing proof on non-judicial paper.
Date. ____________________ Received By Name and & Signature: _________________________________________
Note:- 1. In case of change in the data / particulars new form duly verified from both Drawing & Disbursing
Officer and Office Accounting Head may be furnished to concerned WAPDA Hospital / Dispensary to
update the information.
2. Use extra sheet if required.
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