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(Fobe completed in DUPLICATE)
GP. 69
‘REPUBLIC OF KENYA
PARTI
(Name end address of Ministry/Department)
To: area ores ie AeA Aen Lenin
‘Name: *MS/Miss Mfrs ERD AM... AGREE... YN. 610 is sent herewith for medical examination as a
cand for enporary/onrcvpemanent pleyenvites texted ou by - Months
(COR.N20(1)as.
(Signature)
« (Designation)
Part 1 ofthe form to be completed in duplicate by the officer sending the candidate for examination.
Part? of the form to be completed by the Medical officer, who will return one copy 10 the
Ministry/Department which sent the candidate.
Particulars on reverse to be filled in by candidate before appearing for Medical Examination,
“Delete whichever is inapplicable. ‘Candidate's full mame (in BLOCL letters)
‘The following questions to be answered by the candiate:
1 ‘have youever been an in-patient in hospital or nursing home suffering from any disease or injury?
‘30, give dates, sate nature of disease or injury, which hospital or nursing home. Name of
‘doctor(s) who treated you and whether an operation was performed
Ne ea
zl
