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ANNEXURE.IX
MEDICAL CERTIFICATE OF FITNESS

Candidate must fill the details of the Form-A before medical examination by the Medical Officer in any Government
Hospital. Form B is to be filled by the Medical Officer. The officer will also certify the fitness of the candidate and attest the
photograph of the candidate,

FORM A

1. Name in full (BLOCK LETTERS)

VART' K A VASHTSTI)
2. Age and place of birth
lB W" DEU|r
3. Present Residential Address PLotrtn.ioTQ,&H-t3
Puscain Vihar , Net> bd.l"i-84
4, Permanent Residential Address
S.a-mL at qbove-
5. Details of having suffered from any major illness in last five years.
Any skin related problem
Enlargement or suppression of gland
Asthma
Heart disease
Lung disease
Fainting attacks/Epilepsy
A/Ay
Rheumatism
Appendicitis? ( Give details)
b) Any other disease or accident requiring confinement to bed
and medical for surgical treatment? ( Give details)

6. a) Details of vaccination in last three year. s) turtl-

b) Details of vaccination for Covid-lg. {1't & 2id Dose) b) is't to.e: 4 -o t -zZ zd oos ; ot - aL ZL

7. Have you or any of your immediate family member has been

afflicted with
Rheu matism/Arth ritis, Asthma
Epilepsy or mental illness of any kind?
NO
8. Have you at any time suffered from any form of psychiatric
disorder? Give details. N0
9. Furnish the following particulars concerning your family: Agl " 49t
Father's age and state of health he(Jh' Qoo I
1.0 lf not alive, Father's age at the time of his death and cause.
-MA -
7t Mother's age and state of health h4 46.+
h,lrth - 4oJd
t2 lf not alive, Mother's age at the time of her death and cause. *N**
I declare that the above information is the best of my belief, true and correct. I also affirm that I have not received a
disability certificate on account qt
^ny .1lrqK'condition' {M
Signature of Medical
i$$*t pandsiarE's srG,NAruRE)

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FORM B

Candidate's Eyesight
L'6/t \r*\k [J>rL -
Any known Allergies { details}
* No -
Last Surgical lntervention ( if any) with cause/reason

Any chronic medical condition

Any congenital medical condition

Any Disability (orthopedic) Muscular, nerve etc.)

MEDICAL CERTIFICATE OF FITNESS

?
r hereby certify that r have medicaily examined n)6./vrr,/vr*..,)/..A*.T..1.KA....^ilAS.ttt.S-.Ifl........,.....tor admission in the
National lnstitute of Fashion Technology. The canflidate has no disease (communicable or otherwise) or any constitutional
weakness or bodily infirmity except ..................I1...*1*....,......... ..... I further certify that I am not related to the
candidate and not known to any member of his/ her family.

Signature of Medical

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