ASSAM AGRICULTURAL UNIVERSITY

Jorhat ,Assam ,India , PIN: 785013

MEDICAL FITNESS CERTIFICATE FOR ADMISSION TO THE UNDERGRADUATE

/ POSTGRADUATE / Ph D COURSES

TO BE FILLED IN BY THE APPLICANT :

1.NAME OF THE APPLICANT ……………………………………………………………………………………………………………………………………………….

2.AGE : ……………………………… 3.SEX : M / F 4. WEIGHT: …………………….. 5.HEIGHT : ……...... ft. ………… inches
6. DO YOU HAVE ANY CHRONIC DISEASE CONDITION OR PHYSICAL DEFORMITY : Yes / No. ( If yes ,give the details of the
condition )
………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………..

I , Mr /Miss/Mrs ……………………………………………………………………………………........ Son / Daughter of ………………………………………

………………………………………………………………......................... and a resident of ………………………………………………………………………..
………………………………………………………………… hereby declare that the information provided above by me are true .

( Signature of the parent / Guardian ) ( Signature of the Applicant )

Date : ……………………………….. Date: ………………………………….

TO BE FILLED IN BY THE EXAMINING DOCTOR :

7. NAME : …………………………………………………………………………………………………………………………………………………………………………….
8.IDENTIFICATION MARK: …………………………………………………………………………………………………………………………………………………….
9. BLOOD GROUP: …………………………….. 10. PULSE : ………………………. 11. BLOOD PRESSURE : …………………………………………….

12. CHEST: ………………………………………………………………………. 13.CVS: …………………………………………………………………………………..

14. CNS:…………………………………………………………………………… 15. ABDOMEN:……………………………………………………………………….

16.EYES: …………………………………………………………………………. 17.EARS : ……………………………………………………………………………….

18. ANY OTHER FINDINGS ( If found please give the details) : ………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………...
………………………………………………………………………………………………………………………………………………………………………………………

Certified that Mr /Miss/Ms. …………………………………………………………………………………… age …………………….. son/daughter of

..………………………………………………………………………………….. and a resident of ……..…………….....................................................
…………………………………………………………………………… and whose signature is given below ,Is examined by me . In my opinion
He / She is physically fit / Unfit to pursue higher studies.( If found to be unfit , please mention the reason
..……………..………………………………………………………………………………………………………………………………………………………………………….. )

(Signature of the Applicant ) ( Signature of the certifying doctor )

Date of issue :…………………………….. Name : Dr. ……………………………………………………………….

Place : ………………………………………. Registration no.:………………………………………………………
Seal:

Address :……………………………………………………………………
………………………………………………………………………………….

( N.B.: i. Medical certificate must be obtained from a Government doctor

ii. This medical certificate must be produced at the time of counselling and admission )