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Medical_Dental_Claim_Form

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					                                  SINGAPORE SHOOTING ASSOCIATION
                                  MEDICAL / DENTAL CLAIM FORM

PERSONAL INFORMATION


1. Name (as per NRIC/Passport): __________________________________________________________


2. NRIC No. (Singaporean / SPR) or FIN (Foreigner): ___________________________________________


3. Telephone No. : __________________ (O) _____________________ (H) ____________________ (HP)


4. Designation: _________________________________________________________________________




CLAIMS INFORMATION

Please indicate number of receipts for self:-

a)      Medical -         _____                             b)       Dental -          ____


Please staple all original receipts in date order behind claim form.




DECLARATION

I hereby certify that all information/particulars given on this form are true and correct.




__________________________________                                                     ________________
      Signature of Staff Member                                                              Date




FOR FINANCE USE


Approved By:     _________________                   Signature/Date: ______________________________


Reimbursement Date:       __________________


a) Med. B/F      ________         Amt      _______          Med. C/F            ________

b) Den. B/F      ________         Amt      _______          Den. C/F            ________


Checked & Updated By:     ___________________               Date: ______________



                                                                                              Updated as of 1 December 2007

				
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