We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
You are on page 1/ 4
(To be completed in DUPLICATE)
ane
Pe ae
a
To: The Medical Officer ve
‘Name: *Mr/Miss/Mrs is sent herewith for medical examination as a
candidate for *temporary/coniract/permanent employmentifitness to extend toug by “months
Terk waeitinien, Ss
os
run acenmancare or ania iXanikarip
ssa came’ a Gort eae eas oes eae aa
“helshe is *fiVunfit for *temporary/contrucy/permanent service/evtension of tour by
Months (COR. N20 (1)) as
Part 1 of the form to be completed in duplicate by the officer sending the candidal for€xamination, Part
2of the form to be completed by the Medial officer, who vill return one eopy to the
Ministry/Depertment which sent the candidate
Particulars on reverse to be filled in by candidate before appearing for Medical Examination, *Delete
whihever ss inapplicable Candidate's ful name (in BLOCL leteers)
“The following quescions fo be answered by the candidate:
1) have you ever been an in-patient in hospital or aursing home suffering feqm any discase or injury?
If so, give dates ste nature of dea or injury, which hospital or nursing home. Name of
ocior(s) who treated you snd whether an operation was performed sini
2. Apart trom above, have you ever recrived medical treatment for any serious disease or injury? I
20 give particulars.
to
Signature of Candidate
GPK
