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 affliction or bodily infirmity/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$(ualification for the em"loyment he/$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 : + + + + + + + ++ ++ + + ++ + + + ++ + ++ + + + + + + on full ex"iration : + + + + + ++ + ++ + ++ + + ++ + + + + ++ + + + ++ + difference (ex"an$ion) : Weight in -g :

Che$t ,ea$urement in

*eight :

Cardio . /a$cular Sy$tem / 0e$"iratory Sy$tem *i$/*er vi$ion i$ normal *y"ermetro"ic/ myo"ia/ 1$tigmatic/

(*ere enter the degree of defect and the $trength of correction gla$$e$) *earing i$ normal& defective (much or $light) 2rine + o$$ chemical examination $ho%$ :+ (ii) Sugar (iii)State

(i) 1lbumen $"ecific gravity

3er$onal mar)$ (at lea$t t%o $hould be mentioned) for identification mar)$: (i) (ii) Signature: 0an): e$ignation: ,ember$: 4) 5) 6) Station: 3re$ident

''5'' 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%: 4' State your name in full 5' State your age and birth "lace : :

6' a) *ave you ever had $mall"ox& intermittent or any other fever& enlargement or $u""uration of gland$& $"itting of blood& : a$thma& inflamation of lung$& heart di$ea$e& fainting attac)$& rheumati$m& a""endiciti$7 or b)1ny other di$ea$e or accident re(uiring confinement to bed and medical or $urgical treatment7 : 8' When %ere you la$t vaccinated7 9' 1re you or any of your near relation$ been affected %ith con$um"tion& $erofula& gout& a$thma& fit$& e"ile"$y or in$anity7 :' *ave you $uffered from any form of nervou$ne$$ due to over %or) or any : other cau$e7 ;' Furni$h the follo%ing "articular$ concerning your family:
Father<$ age& if living and $tate of health (4) Father<$ age at death and cau$e of death (5) Number of brother$ living& their age$ and $tate of health (6) Number of brother$ dead& their age$ at and cau$e$ of death (8)

,other<$ age& if living and $tate of health (4)

,other<$ age at death and cau$e of death (5)

Number of $i$ter$ living& their age$ and $tate of health (6)

Number of $i$ter$ dead& their age$ at and cau$e$ of death (8)

I declare all the above an$%er$ to be& to the be$t of my belief& true and correct' Candidate<$ Signature !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !! N=T>: The candidate %ill be held re$"on$ible for the accuracy of the above $tatement' ?y %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'