PAHARPUR COOLING TOWERS LTD.

8/1/B, Diamond Harbour Road,

Caicutta-700 027

Medical expenses incurred for April 30,

August 31,
December 31

( Strike out inapplicable ones)

REIMBURSEMENT OF MEDICAL EXPENSES

Please. reimburse the following medical expenses, as per the rules of the Company's Medical Assistance
Plan. I confirm that these receipts are for actual medica! expenses incurred by me on myself, spouse,
children and dependent parents:
Bill No.1 Amount
51. No.
I Date
I Cash Memo No. I Parti cui ars
I Rs. P.

Total Checked by I Total I

In words
Basic Salary
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Signature

Name & Dept.

No.

For Accounts Use

Claim passed for Rs

Remarks:

A pproved by :
Date: