Date (day/month/year):

For the attention of:

Multi-Property Director of Human Resources

Delta Hotel, Element City Center, Element West Bay and Al Samariya Autograph Collection hotels

Dear Sir/Madam,

I, Dr. ______________________________, have completed the following medical tests and certify to confirm that
these tests are authentic and conducted by a reliable and licensed medical institution. I also certify that Mr./Ms.
__________________________________________ is medically fit to work.

1. Physical Examination: Fit Not Fit Copy of the Report Attached

Remarks:
a. Height (cm) : b. Weight :
c. Blood Pressure d. Pulse Rate:
Remarks:
e. Skin Problems Clear Not clear Copy of the Report attached
If Not Clear, please specify the skin problem and location:

2. Medical History: Clear Not Clear Copy of the Report attached

Remarks:

3. Chest X-Ray Clear Not Clear Copy of the Report attached

Remarks:

4. Blood Test:
a. HIV / AIDS Screening: Positive Negative Copy of the result attached
Remarks:

b. Hepatitis B: Positive Negative Copy of the result attached

Remarks:
c. Hepatitis C: Positive Negative Copy of the result attached
Remarks:

Other observation or remarks concerning general physical condition or any pre-existing sickness which may affect
the work:

Name of Doctor/Physician: License Number:

Address :

Telephone No.: Fax No.:

Signature and stamp: