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