CERTIFICATE OF PHYSICAL FITNESS BY THE CIVIL MEDICAL BOARD

Signature of the Candidate:

I/We do hereby certify that I/We have examined (Full Name) Thiru/Thirumathi/Selvi/r! ! ! ! ! !
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! a candidate for em"loyment under the
#overnment a$ ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! in the ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! de"artment and %ho$e $ignature i$ given above
and cannot di$cover that he/$he ha$ any di$ea$e& communicable or other%i$e& con$titutional
a'iction or bodily in(rmity/exce"t that hi$/her %eight i$ in exce$$ of/belo% the $tandard
"re$cribed& or exce"t)
I/We do not con$ider thi$ a di$*uali(cation for the em"loyment he/$he $ee+$) ,i$/,er age i$
according to hi$/her o%n $tatement ! ! ! year$ and by a""earance about ! ! ! year$) I/We
al$o certify that he/$he ha$ mar+$ of $mall"ox/vaccination)
on full in$"iration :
- - - - - - - -- -- - - -- - - - -- - -- - - - - - -
Che$t .ea$urement in on full ex"iration :
- - - - - -- - -- - -- - - -- - - - - -- - - - -- -
di/erence (ex"an$ion) :
,eight : Weight in 0g :
Cardio 1 2a$cular Sy$tem / 3e$"iratory Sy$tem
,i$/,er vi$ion i$ normal
,y"ermetro"ic/ myo"ia/ 4$tigmatic/
(,ere enter the degree of defect and the $trength of correction gla$$e$)
,earing i$ normal& defective (much or $light)
5rine - o$$ chemical examination $ho%$ :-
(i) 4lbumen (ii) Sugar (iii)State
$"eci(c gravity
6er$onal mar+$ (at lea$t t%o $hould be mentioned) for identi(cation mar+$:
(i)
(ii)
Signature:
3an+: 6re$ident
e$ignation:
.ember$: 7)
8)
9)
Station:
) ) 8 ) )
The candidate mu$t ma+e the $tatement re*uired belo% "rior to hi$ medical
examination and mu$t $ign the declaration a""ended thereto) ,i$ attention i$ $"ecially
directed to the %arning contained in the note belo%:
7) State your name in full :
8) State your age and birth "lace :
9) a) ,ave you ever had $mall"ox& intermittent
or any other fever& enlargement or
$u""uration of gland$& $"itting of blood& :
a$thma& in:amation of lung$& heart di$ea$e&
fainting attac+$& rheumati$m& a""endiciti$;
or
b)4ny other di$ea$e or accident re*uiring
con(nement to bed and medical or
$urgical treatment; :
<) When %ere you la$t vaccinated;
=) 4re you or any of your near relation$
been a/ected %ith con$um"tion& $erofula& :
gout& a$thma& (t$& e"ile"$y or in$anity;
>) ,ave you $u/ered from any form of
nervou$ne$$ due to over %or+ or any :
other cau$e;
?) Furni$h the follo%ing "articular$ concerning your family:
Father@$ age& if living
and $tate of health
Father@$ age at death
and cau$e of death
Number of brother$
living& their age$ and
$tate of health
Number of brother$
dead& their age$ at and
cau$e$ of death
(7) (8) (9) (<)

.other@$ age& if living
and $tate of health
.other@$ age at death
and cau$e of death
Number of $i$ter$ living&
their age$ and $tate of
health
Number of $i$ter$ dead&
their age$ at and cau$e$
of death
(7) (8) (9) (<)
I declare all the above an$%er$ to be& to the be$t of my belief& true and correct)
Candidate@$ Signature
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
! !
NATB: The candidate %ill be held re$"on$ible for the accuracy of the above $tatement) Cy
%illfully $u""re$$ing any information he %ill incur the ri$+ of lo$ing the a""ointment and if
a""ointed& of forfeiting all claim to $u"erannuation allo%ance or gratuity)