TO WHOMSOEVER IT MAY CONCERN

I Dr. __________________________ have clinically examined Mr / Ms ____________________

Age__________ (Years) date of birth ____________and certify that his / Her:

Height : ___________ cms

Weight: ____________ Kgs

Body Mass Index (BMI): _______

Colour Vision: _____________

Vision Near Vision: _______________

Distant Vision: _____________

Whether corrected by Contact lenses: Yes / No

Correction :

Signature of the Doctor

Name of the Doctor

Registration no:

Stamp

Date of issuance :