Wellness declaration form

Tata Motors Ltd.

(Please do not leave any field blank, provide supportive explanation where needed).

Name: Chaudhari Rahul Motilal

________________________________________________________________
(Surname) (First Name) (Middle Name)

Age: _ 28

_________

E-mail ID: rahulchaudharicr@gmail.com Mobile: 8605730358

____________________________________________ _________________________

Identification Mark : Mole on left hand finger

_________________________________________________________________________

Please tick appropriate box:

No Yes If yes kindly provide details like Diagnosis, treatment
taken
Heart Disease No
Convulsions/Fits/Seizures No
TB (Tuberculosis) on No
treatment
Kidney Disease No
Operated in the past No
Hospitalization in past No
Psychiatric illness No
Leprosy under treatment No
Blood disorder like No
Polycythaemia, Thalassemia
major, Haemophilia, Sickle
cell disease
Receiving blood transfusion No
periodically
Any major skeletal/muscular No
deformity
Normal eye sight in both eyes No
with or without spectacle

I am furnishing the above information voluntarily and by my free will. As of date, I certify that the above information
furnished by me is true and correct to the best of my knowledge and belief. I am healthy and would be able to carry out all
job related responsibilities.

I also authorize the HR, by my free will, to share this information with Health department of Tata Motors.

Signature of the candidate:

Name: Rahul Motilal Chaudhari

Date: 08/12/2022