CS Form No. 211 i Revised 2017 MEDICAL CERTIFICATE (For Employment) INSTRUCTIONS 2. This medical certificate should be accomplished by a licensed government physician. bb. Attach this certificate to original appointment, transfer and reemployment. ¢. The results ofthe following pre-employment medicaliphysical/mental examinations ‘must be attached to this form: 1 Blood Test 1D Urinalysis 1D chest x-Ray 1D rug Test Psychological Test CO) Neuro-Psychiatric Examination (if applicable) FOR THE PROPOSED APPOINTEE [NAME (Cast Name Fret Namo, Namo Extension (Tang) and Middle Namey "AGENCY [ADDRESS [ADDRESS AGE Sex civic STATUS PROPOSED POSITION FOR THE LICENSED GOVERNMENT PHYSICIAN | hereby certty that | have reviewed and evaluated the attached examination results, personally examined the jabove named individual and found himher to be physically and medically CIFIT/ UNFIT for, ‘employment. [SIGNATURE over PRINTED NAME OF LICENSED GOVERNMENT PHYSICIAN: OTHER INFORMATION ABOUT THE PROPOSED APPOINTEE |AGENCY/Afiliaon of Licensed Goverment Physician TICENSENO, HEIGHT on [WEIGHT xa] BLOOD ‘Bare Foot Sitpped TYPE OFFICIAL DESIGNATION DATE EXAMINED