MODEL FOR CCSE-4

I do hereby certify that I have examined (Full name ) --------- S. Raja Annamalai--------------------------------------

a candidate for employment under the government of ---------Tamil Nadu-------------------- in the -----CCSE IV----------

--------- services as -----------Junior Assistant (or) Typist (or) Steno-Typist ---------------------in------Agricultural

Engineering Department, Chennai – 5---------------------------------------------------------------------------------------------------.

and cannot discover that he/she has any disease, communicable or otherwise constitutional affection or bodily

infirmity/except that his/her weight is in excess of/below the standard prescribed or except.

I do not consider this a disqualification for the employment he/she seeks. His/Her age is according to

his/her own statement -----------25----------------- years and by appearance about ------------25--------------- years.

I also certify that he/she has no marks of smallpox vaccination.

Chest measurement in inches:

On full inspiration: 90 cm
On full expiration: 85 cm
Difference (expansion): 05 cm

Height (in cm) : 172 cm

Weight ( in kg) : 75 kg

His/Her vision is normal

Hypermetropia (….......................................................................................)

(Here enter the degree of defect and strength of correction glasses)

Myopia (......................................................................................................)

(Here enter the degree of defect and strength of correction glasses)

Astigmatic (Simple of Mixed)

(Here enter the degree of defect and strength and of correction glasses)

Hearing is normal defective (much or slight)

Urine – Does chemical examination show (I) albumen.

(Sugar) state specific gravity

Personal mark (at least two identify marks should be mentioned):

1. ......A mole on the center on the center nose..............................................................................................

2. …..A scare on the left foot.............................................................................................................................

Signature*

Reg. No:

Designation:

Station:

Dated:

* In the case of Single Medical Officer / In the case of Medical Board. www.ajitnpsc.com, page 1 of 2
 The candidate must make the statement required below prior to his medical examination and must sign the
declaration appended thereto. His attention is specially directed to the warning contained in the note below:

1. State your name in full (IN BLOCK LETTERS) : S. RAJA ANNAMALAI

2. State your age and birth place : Madurai

3. (a) Have you ever had smallpox, intermittent

or any other fever, enlargement or
suppuration of glands, spitting of blood, : No
asthma, inflammation of lungs, heart disease,
fainting attacks, rheumatism, appendicitis?
or
(b) Any other disease or accident requiring
confinement to bed and medical or

4. When were you last vaccinated? : Three years

5. Are you or any of your near relations

been affected with consumption, scrofula, : No
gout, asthma, fits, epilepsy or insanity?

6. Have you suffered from any form of

nervousness due to over work or any : No
other cause?

7. Furnish the following particulars concerning your family:

Father's age, if Father's age at death and Number of brothers Number of brothers
living and state of cause of death living, their ages dead, their ages at
health and state of death and causes of death

(1) (2) (3) (4)

52, Normal NIL 02, Normal NIL

Mother's age, Mother's age at death and Number of sisters living, Number of sisters
if living and state of cause of death their ages dead, their ages at
health and state of death and causes of death

(1) (2) (3) (4)

NIL 45, Cardiac arrest 01, Normal NIL

I declare all the above answers to be, to the best of my belief, true and correct.

Candidate's Signature

NOTE: The Candidate will be held responsible for the accuracy of the above statement. By willfully suppressing any
information he will incur the risk of losing the appointment and if appointed, of forfeiting all claim to superannuation
allowance or gratuity.

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