WAPDA MEDICAL DIRECTORATE 1 Colored
Photograph
MEDICAL REGISTRATION FORM - A
New Registration Change
Version 4.2, Revised On 14-10-2023
1. Company / WAPDA WING 2. Family-Id (for office use only)
c o o r d i n a t i o n w i n g
3. C.N.I.C. No. 4. Registration Status
(Contract, Regular, Retired, Deceased, Widow, Deputation, Outstation)
3 2 3 0 4 - 1 1 1 1 9 3 2 - 7 R E G U L A R
5. Employee’s Name
H A Z O O R B A K H S H L A G H A R I
6. BPS 7. Designation
1 5 ACC O UN T - A S S I ST AN T
8. Birth Date (DD-MM-YYYY) 9. Joining Date (DD-MM-YYYY) 10. Last Posting Date (DD-MM-YYYY)
0 9 - 0 6 - 1 9 8 0 1 1 - 0 2 - 2 0 0 6 2 7 - 0 8 -2 0 1 7
11. Father’s / Husband’s Name
M U H A M M A D A S H I Q
14. Family 15. Blood 16. Facility
12. Gender 13. Marital Status
Size Group (Medical Facility/Cash Allowance)
M A L E M A R R I E D 06 B + V E
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 / Death Date
(DD-MM-YYYY)
- -
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)
D - 6 7 T H E R M A L P O W E R S T A 0 6 6 2 9 2 2 0
T I O N C O L O N Y M - G A R H 1 9 3
27. Email Address
h a z o o r b a k h s h l a g h a r i @ g m a i l . c o m
28. Mobile Number 29. Registration Date (DD-MM-YYYY)
0 3 0 1 - 4 1 7 5 3 6 5 - -
Signature (MS/DMS) Employee’s Signature
* Date of Retirement (In case of a retired employee), Date of Death (In case of Deceased / Widow Employee)
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WAPDA MEDICAL DIRECTORATE
MEDICAL REGISTRATION FORM - B
31. 32. Date of Birth (DD-MM-YYYY) /
Sr.# 30. Dependant’s Name
Relationship C.N.I.C No.
S A E E D M A I 0 1 - 0 1 - 1 9 8 1
01
WIFE 32304 - 146 8994 - 8
Z A H R A B A T O O L 0 1 - 0 1 - 2 0 0 7
02
DAUGHTER 32304 - 8465553 - 3
Z A I N - U L - A B I D E E N SON 2 8 - 0 9 - 2 0 0 9
03
32304 - 6359228 - 7
A M A R A B A T O O L 0 8 - 0 8 - 2 0 1 0
04
DAUGHTER 32304 -8 5700 53 - 0
M U H A M M A D U M A R A M I N SON 0 1 - 0 7 - 2 0 1 4
05
3 2304 - 324 2974 - 3
M U H A M M A D A S H I Q 0 1 - 1 1 - 1 9 6 1
06
FATHER - -
32304 72 5868 0 7
S U G H R A I N M A I 0 1 - 0 1 - 1 9 6 3
07
MOTHER 32304 - 95 59849 - 6
- -
08
- -
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.
Employee’s 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 employee’s 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 case of
Attested copy of CNIC of employee and his/her dependents having age of
1 18 years or above.
5 BPS (1-15) issued from Drawing & Disbursing Officer (in
original).
Attested copy of Form-B of all children issued by NADRA (Mandatory) and
2 Birth certificate is acceptable having age below 5 years.
6 Nikah-Nama (where applicable).
Non-marriage and non employment declaration on non-judicial paper from In case of cash medical allowance of a retired employee his
3 the employee for his/her daughter age above 25 years (renewable yearly).
7
option/Application (in original).
Female married employees submit the declaration of not
Attested copy of Pension Book of retired employee (family Pension Book in
4 case of deceased employee).
8 availing MF/CMA from any other institute and dependency
proof of Husband upon her on non-judicial paper.
Date: ____________________ Received By Name & Signature: _____________________________________________
Note:- In case of change in the data/particulars new form duly verified by both the Drawing and Disbursing Officer
and Office Accounting Head may be furnished to the concerned WAPDA Hospital / Dispensary to update the
information.
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WAPDA MEDICAL DIRECTORATE
MEDICAL REGISTRATION FORM - C
New Registration Change
Employee / Dependent Photographs
HAZOOR BAKHSH LAGHARI
Employee Name: ___________________________ ACCOUNTS ASSISTANT
Designation: ________________________
2959
Medical Facility No: __________________________ coordination wing
Company/Wing: _____________________
Recent Photograph of Recent Photograph of Recent Photograph of
Recent Photograph of
Dependent No.1 Dependent No.2 Dependent No.3
Employee
Name: Name: Name: Name:
CNIC: CNIC: CNIC: CNIC:
Recent Photograph of Recent Photograph of Recent Photograph of
Recent Photograph of
Dependent No.5 Dependent No.6 Dependent No.7
Dependent No.4
Name: Name: Name: Name:
CNIC: CNIC: CNIC: CNIC:
Recent Photograph of Recent Photograph of Recent Photograph of Recent Photograph of
Dependent No.8 Dependent No.9 Dependent No.10 Dependent No.11
Name: Name: Name: Name:
CNIC: CNIC: CNIC: CNIC:
Employee Signature: ____________________ Date: ________________
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