A SINGLE MEDICAL OFFICER CERTIFICATE OF PHYSICAL FITNESS BY —————————" THE CIVIL MEDICAL BOARD. Signature of person Examined 1 do hereby certify that I have examined (Full Name ... ? candidate for employment under the Govern ment of Tamilnadu / India in the Service as... and can’t discover he / she has and disease communicable or otherwise constitutional affection of bodily infirmity except that his / her weight is in excess / below the standard prescribed or except I do not consider this a disqualification for the employment he / she seeks His / Her age according to his / her own statement .. .. years and by appeararice about. years as ascertained by my Physical Examination, Jalso certify that he / she has marks of smallpox / vaccination. on full inspiration .. Chest Measurement | on full expansion Height ... difference (expansion). Weight His / Her vision is normal Hypermetropic (. (Here enter the degree of defect and the strength of correction glasses) Myopic (... ) (Here enter the degree of defect and the strength of correction glasses) Astigmatic simple or mixed (... ) (Here enter the degree of defect and the strength of correction glasses) Hearing is normal / defective (much or slight) Urine :- Dose Chemical examination show (i) albumen : i) Sugar state specific gravity. Personal Marks (atleast two mentioned) a) @) Signature Name Rank No, Station Date tion