CCS Haryana Agricultural University, Hisar
Form for Reimbursement of Medical Charges (Form AU 5/10)
1. Employee Details
2. Patient & Treatment Information
3. Medical Expenses (Medicines/Tests)
| Sr. |
Name of Medicine / Particulars |
Remarks / Bill No. |
Amount (Rs.) |
|
| TOTAL AMOUNT |
0.00 |
|
4. Declarations (Tick applicable)