Application

DIRECTORATE OF MAHARASHTRA FIRE SERVICE, GOVT. OF Form No./ Roll

MAHARASHTRA STATE FIRE TRAINING CENTER & MAHARASHTRA No.
STATE FIRE ACADEMY ADMISSIONS 2023-24
Admit Card for Physical Examination 2023S01214

Course name : Sub Officer & Fire Prevention Officers Course Level I
Candidate Name : DURGESH ASHOK PATIL
Caste : EWS

Name ol Examination MAHARASHTRA FIRE SERVICES ACADEMY, HANS BHUGRA MARG, KALINA,
Center & Address : SANTACRUZ (EAST), MUMBAI - 400 098

Examination Date : 2023-10-05 (YYYY-MM-DD)

Examination Time : 11:00 AM

Important Instructions :
Documents to be submitted at the lime of Physical Test, attested copies along with original documents of following:
1. Carry hard copy of online application form.
2. Education qualification certificates - Minimum 10th Passed mark sheets along with passing certificate from any recognized board & any other
higher qualification marks sheets along with certificates. (XI / XII / ITI / Diploma / Graduation certificate if applicable).
3. Attested copy's or caste certificate, if applicable.
4. Birth certificate/ school leaving certificate.
5. Carry one latest passport size photograph, pasted on application form if scanned photograph is not proper uploaded during filling of the
application form.
6. Attested copies of Domicile certificate issued by local revenue authorities not below the rank of Tehsildar for verification of citizenship.
7. Sport certificates (Inter - School / Inter - District/ Inter-Stale/ National Level Certificate (If applicable)).
8. Driving License-: HMV / LMV (If applicable).
9. NCC-A/B/C Certificate (If applicable).
10. Civil Defence Basic Course Certificate (If applicable).
11. Home Guard Training Certificate (If applicable).
12. Medical fitness certificate in prescribed format from Medical Practitioner. (MBBS Doctor / Medical Officer)
13. Any other certificates.

Important Note : - Without the Admit Card, entry shall not be provided.
 MEDICAL FITNESS CERTIFICATE
Medical Report History :-

I. Present personal History :-

II. Physical Examination :-
1 Eye Sight – Distant Vision 6/6 without spectacles. Yes/No
2 Colour Blindness. Yes/No
3 Any disease of the skin, which is likely to cause disability or disfigurement. Yes/No
4 The minimum range of expansion of chest after full inspiration should be 5cm. Yes/No
5 Normal hearing without any evidence of present or past disease of the ear, nose and throat. Yes/No
6 Disease of bones and joints of the body Yes/No
7 Past history of mental breakdown of fits. Yes/No
8 No medical deformity. Yes/No
9 Knee knock Yes/No
10 Fat foot :- Yes/No
11 Varicose vein Yes/No
12 Squint eyes Yes/No
13 Teeth Yes/No
14 Speech deficiency such as stammering Yes/No
15 Any major surgery Yes/No
16 Pulse Yes/No
17 Blood Pressure Yes/No

18 ECG Yes/No
19 X-RAY Chest Yes/No
Any physical defect likely to interfere with the efficient performance of discharging life saving and fire
20 Yes/No
fighting services
21 Any other disease Yes/No
22 Remark Yes/No

Certified that Shri. ___________________________son of __________________________aged ______years was examined by me

at _________on_________ and has been declared medically fit for undergoing Fireman’s Training Course(R) at Maharashtra Fire
Service Academy/Regional Fire Training Centre which will involve theoretical and ground training.

Signature & Name with Seal of Medical Practitioner