Medical Reimbursement Form

(This form will help us reimburse your medical expenses .We will make payment by
cheque/NEFT in your name which will be mailed by post at the address mentioned by you/
sent directly to your account. This process will typically take fifteen/three days of time)
1. Campus Selection Procedure Date : _________________________________________
2. Name (as spelled

in the bank account ):

(Please leave a blank space between first name, middle name and last name)
3. Date Of Medical Test: _______________________________
4. Medical Test Details:
Full Medical Test
Only Eye Test
5. Bank details to be provided by the Candidates
S.
No
.

Details Required

Beneficiary Name

Bank Account No.

Bank's Name

Branch Name

Branch Compete
Address

Account Type

IFSC Code
(Mandatory)

PAN No.

(Candidate to Provide the details)

6. Address:

Form No. HR/FRM/TAG/FP/06

Rev. No. 0.0

Effective Date: 15/09/2011

(Please mention the address where you want your cheque to be delivered with Pin
code and Phone number below)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Total amount: _____________________________

Signature: __________________
_______________________

Form No. HR/FRM/TAG/FP/06

Date:

Rev. No. 0.0

Effective Date: 15/09/2011