Professional Documents
Culture Documents
PASTE YO UR
(For Leader/ Manager Job Level) RECENT PASSPRT
SIZE PHO TO GRAPH
(Prospectiv e employ ee should fill in Section 1 to 4 (Attested by the
The Examining Medical Officer w ill fill in Section 5 to 6 Examiner)
________________________________________________________________________
Address: ____________________________________________________________
____________________________________________________________________
____________________________________________________________________
City __________________________________________
Pin:_______________
Mother
Brother (No.)
Sister (No.)
Husband/Wife
Children (No.)
Ty pes of Prev ious Occupation (Pl. describe in brief about company , nature of work, duration in y ears)
Name of Candidate: _________________________________________
Y N Y N
4 I declare that the abov e statements are true and complete to the best of my knowledge and
belief and I agree that the results of this medical ex amination in general terms may be
rev ealed to the company if required. I also fully understand that in case I am declared
medically unfit due to any reason, I shall not be entitled for the employ ment in the company .
Howev er, The decision taken by the company 's doctor/s about my medical fitness will be final
and binding to me.
Date (dd/mm/y y y y ) Signature of Prospectiv e Employ ee
(Ex amining doctor should ensure that candidate has filled up section 1 to 4)
BMI
Chest: Ex piration cms Inspiration cms
Name of Candidate: _________________________________________
Ax is
Y es No
Squint
7 Audiometry Report
8 P.F.T Report
Scars _______________________________________________________
Identification marks:
1 _________________________________________________
2 ________________________________________________
14 Nerv ous Sy stem ____________________
Pupilary Reaction ______________________