PRE-EMPLOYMENT @® LARSEN & TOUBRO FITNESS CERTIFICATE mi>o-oz>0 a i i iy H is rs L F i IY 3 i iy S 5 a E R a fl F i a A a E Fee eT) Name Date of Birth: Age Blood Group: Sex MaleL] Female(] | Marital Status: Married] Unmarried [1] Address. Any allergy / Disability / Pre-existing disease: Date Signature of Canto Height | Weight Near LE._RE. Hearing cms gs. | Vision: Distant L.E.R.E..| Let Ear. Colour Vision Right Ear BP. Pulse Rate: Resp. Rate cvs: RS: ‘Abdomen: Any other Findings: BC - Hb gm%| TLC Toumme% | DLC = Poocce boc Econ M BLOOD FBS mg%| BUN mg%| Creatinine mg% URINE Routine X-Ray Chest ECG Tr: hereby cerlfy that | have examined Mr/Ms. on and find him FIT / UNFIT for employment. Remarks i unfit: Signature & Seal Reg. No. ‘Address /Tel No. | declare that the above information is true and correct to the best of my knowledge and | am not suffering from any disease / illness, the presence of which | have not revealed. | fully understand that any misrepresentation of this declaration could lead to the termination of my offer / appointment. In case of any discrepancy arising out of my declaration, | will undergo the medical check-up by the company’s suggested doctor and their findings will be fully binding on me and action thereon towards my employment will be accepted by me. | give my consent to L&T to seek further information, if any, from me directly or from any appropriate doctor. Signature of Candidate: Date: usy201.*To be signed by 2 doctor with minimum M.8.8.S. Qualification PTO.Any additional information- By candidate: Recommendation by Doctor: Remarks by Doctor: * OK OK OK OK