WAPDA MEDICAL DIRECTORATE 1 Colored
Photograp
MEDICAL REGISTRATION FORM - A h
New Registration Change
Version 4.2, Revised On 14-10-2023
1. Company / WAPDA WING 2. Family-Id (for office use only)
WATER WING
3. C.N.I.C. No. 4. Registration Status
(Contract, Regular, Retired, Deceased, Widow, Deputation, Outstation)
5. Employee’s Name
6. BPS 7. Designation
8. Birth Date (DD-MM-YYYY) 9. Joining Date (DD-MM-YYYY) 10. Last Posting Date (DD-MM-YYYY)
11. Father’s / Husband’s Name
14. Family 15. Blood 16. Facility
12. Gender 13. Marital Status Size Group (Medical 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 / Death Date
(DD-MM-YYYY)
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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 Date (DD-MM-YYYY)
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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. Dependent’s Name
Relationship C.N.I.C No.
01
02
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03
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04
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05
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06
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07
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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.
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 dependents
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
TO BE FILLED BY THE WAPDA HOSPITALattestation from Last/Retiring Office is
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 age of 18 years or above.
5 case of
BPS (1-15) issued from Drawing & Disbursing
Officer (in original).
Attested copy of Form-B of all children issued by NADRA
2 (Mandatory) and
6 Nikah-Nama (where applicable).
Birth certificate is acceptable having age below 5 years.
Non-marriage and non-employment declaration on non-judicial In case of cash medical allowance of a retired
3 paper from
7
employee his
The employee for his/her daughter age above 25 years (renewable Option/Application (in original).
yearly).
Female married employees submit the declaration
Attested copy of Pension Book of retired employee (family Pension
4 Book in case of deceased employee).
8 of not 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
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information.
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WAPDA MEDICAL DIRECTORATE
MEDICAL REGISTRATION FORM - C
New Registration Change
Employee / Dependent Photographs
Employee Name:____________________________.Designation:_________________________ __
Medical Facility No: Company/Wing: ________________________
Recent Photograph Recent Photograph Recent Photograph
Recent Photograph of
of Dependent of Dependent of Dependent
Employee
No.1 No.2 No.3
Name: Name: Name: Name:
CNIC: CNIC: CNIC: CNIC:
Recent Photograph Recent Photograph Recent Photograph
Recent Photograph
of Dependent of Dependent of Dependent
of Dependent No.4
No.5 No.6 No.7
Name: Name: Name: Name:
CNIC: CNIC: CNIC: CNIC:
Recent Photograph of Recent Photograph Recent Photograph Recent Photograph
Dependent No.8 of Dependent of Dependent of Dependent
No.9 No.10 No.11
Name: Name: Name: Name:
CNIC: CNIC: CNIC: CNIC:
Employee Signature: Date:
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