ASSAM NURSES’ MIDWIVES’ & HEALTH VISITOR’S COUNCIL SIX MILE, KHANAPARA, GUWAHATI-22 REMUNERATION BILL FORM Name of Examiner Designation Address Examination held on : : : : 1. Name of the Institutions : i)____________________________________________________ ii) ___________________________________________________ iii)___________________________________________________ 2. Name of the Examination Centre: i)____________________________________________________ ii) ___________________________________________________ iii)___________________________________________________ 3. Number of students examine for : Oral and Practical 4. No. of Answer script evaluated : 5. No. of question paper set : 6. Date of journey (To) (Return) : on ___________ from _______________to ________________ : on ___________ from _______________to ________________ (To) (Return) : on ___________ from _______________to ________________ : on ___________ from _______________to ________________ (To) (Return) : on ___________ from _______________to ________________ : on ___________ from _______________to ________________ A. Travel Expenses : Mode of journey, by : ____________________ Rs. _________________ (Train/Bus Ticket must be submitted) Others : ____________________ Rs. _________________ (B) D.A. @ Rs. __________ X No. of days_________ Rs. _____________ (Appear tour Diary must be enclosed herewith for settlement of Bill) TOTAL BILL AMOUNT OF Rs.__________________ Claimant Signature ________________________________________________________________________ OFFICE USE ONLY 1. Honorarium: i. No. of student examine for Oral & Practical :- Honorarium ii. No. of Answer script evaluated :- Honorarium iii. No. of Question Paper Set :- Honorarium iv. Travel Expenses :v. DA @ Rs._____________ x No. of days ________ vi. Others :Total Bill Amount = Less Advance Adjusted Net Payable Amount Rs. ________________. Rs. ________________ Rs. ________________ Rs. ________________ Rs. ________________ Rs. ________________ Rs. ________________ Rs. ________________ Rs. ________________ Rs. ________________ Registrar MONEY RECEIPT Receipt with thanks from Registrar, Assam Nurses’ Midwives’ & Health Visitors’ Council a sum of Rs._____________ (Rupees _________________________________________________________________) as TA/DA/Honorarium. Recipient Signature
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