COMPULSORY HEALTH CERTIFICATE FOR

SHRI AMARNATHJI YATRA 2023

Please paste
one recent
PART A: (TO BE FILLED BY APPLICANT) passport size
1. Rajendra K Worlikar
Name _______________________________S/o;D/o; W/o ___________________________________
Kashinath A Worlikar photograph
here
2. 110/E, Sonabai Sadan Gd. Floor Worli Koliwada Mumbai - 400 030.
Address ___________________________________________________________________________
3. Date of Birth _____/_____/______ 6588 2576 3454 Blood Group: ____
29 09 1970 Aadhaar No. ______/______/_______ A+ve_____
4. Mole on Nose
Identification mark: ___________________________________________________________________
Age limit:
a) For Yatri: Should not be less than 13 Years or more that 70 Years old.
b) Women with pregnancy should not be pregnant for more than 6 weeks, are allowed to perform Yatra Pilgrimage.

5. DECLARATION: Have you suffered from or have history of any of the following:
S.No Condition Yes No S.No � Condition Yes No
A) Breathlessness � No B) Diabetes No
C) Respiratory/ lung ailment No D) High Blood pressure No
E) Blood disorder No F) Asthma No
G) Bleeding tendencies No H) Epilepsy No
I) Heart ailment D D No J) Nervous breakdown D D No
K) Joint Pains No L) High altitude/mountain sickness No
M) Discharge from ear No N) History of stroke/ paralysis No
O) Are you a smoker No P) Are you pregnant (applicable to female Yatris)

No
History of Heart Attack; if yes, please specify_______________________________________
No
History of sudden death in family members; if yes, please specify_______________________
No
Any major injury in the past; if yes, please specify___________________________________
No
Any other ailment; if yes, please specify___________________________________________
No
History of surgery; if yes, please specify___________________________________________
No
Are you undergoing under any medication; if yes, please specify________________________
No
Are you allergic to drugs, foods and chemicals; if yes, please specify_____________________

I hereby declare that the particulars given above are true to the best of my knowledge and belief, and nothing has been concealed.

Date_________ Signature/ thumb impression of the Applicant)

PART B: (TO BE FILLED BY AUTHORISED MEDICAL AUTHORITY)

On the basis of information furnished by the applicant, detailed examination and the necessary investigations, it is
certified that Mr/Ms/Mrs ___________________________________ is fit to undertake the journey to the Shri
Amarnathji Holy Cave Shrine.
Details of any specific test conducted before issuing the certificate: _________________________________

Name of the Doctor______________________________

Designation: ___________________________________ Signature and seal of Authorized Medical Authority

Date of issue: __________________________________ MCI/ State Medical Council Registration No: ........................