Sri Lanka Air Force

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Request to cover medical expenses under medical welfare fund (For retired members)

Service No

Rank at Retirement

Name

Nearest SLAF Station

Telephone No

E-mail Address

Age

Marital Status

Description of the sickness by applicant

To Whom treatment obtain Self Spouse

Name

Age

Type of Treatment

Type of Authority Requested

Treatment Date

Place of treatment planned to obtain / obtained:

Name of Consultant:

Approximate amount of expenditure:

Details of surgical/
medical items required
(if any)

Required medical documents Attached Not Attached

Medical Document 1

Medical Document 2

Medical Document 3

I hereby declare that the particulars entered above are correct.

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