Confidential

PUBLIC SERVICE OF PAPUA NEW GUINEA (FOR OFFICE USE ONL Y)

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Certificate of birth produce

MEDICAL CERTIFICATE
. Checked-and Returned · · ·

PERSONAL STATEMENT . .
Any wilfully incorrect or misleading statement or omission will render the candidate liable to disqualification: · ·. · . · ·
Questions should be read carefully before the answers arc written in, and no question should be answered by inserting a story ~hen the
answer is "no". ·
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II Surname. Given Names: Date of Birth and Ycar:

i co~ I 1r I t~9b.
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i Address·
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I Present Occupation: Position and Department for which nominated:
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Family History (Please give details of the state of health of parents, brnthcrs and/or sisters.)

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I Questions Anrwen Explanatory Notes

i Yes/No
f I. Hu there beai any tubemiJosis. diabetei, rheumatism. c:aocer,

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insanity or my other nervous cooditi00 in yourself or any other
mcmber of 1bc: family. If 10 l:ive puticulan ~
I 2. Have u ever Nffered from;
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j (a) Spitin2 of blood. influenza, or a neniru,at coucll?
(b) Rbeul!latic fr:va-. diabetes. palpit.alion. fainting.
I breathlessness, disease of the heart or lungs. any affection
of the lcjdaey or bladder, stricture?
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(c) Any dfectiorl of the stomach. liver or bowels. indigestion.
diarrhoea, coastioalion. 11nnendicitis. piles or rupture tLO
(d) Epilepsy or fns of any kind
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(e) Discharge from can? }--tu
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(1) Dermatitis, any skin eruption « skin cancer ·
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i ). Have you ever bad any accident or surgical treatment? If so give
full details.
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I 4. Have you ever been rejected for life assurance ~r, for h ~
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reasoru, for admissioo to any Government service? If so give full
details
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Have vou eVl:1' been in receipt of a pensioo for medical reasons?
5.
If so !rive full details. VD
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6. Arc you in good beatth now? • '--[~ ·-

I 7. When were you last under medical treatment?
(n) Date .... .... .... .... .... .... .µ;)
I (b) For wb-1 re..on? .... .. .. .. .. ....

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Do you ,uffer from any seva-e hea&che.•? ~ I
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, . r . t be filled in but not signed by the candidate before the cxammabon. Signature is to be affixed in
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the presence o
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Note: The above portion ,orm IS O f
Examining doctor. . _ / Q {0 / ~-'-~.. .,.. ............... .
s;'"""re ........ ... /:...; J 6 = ································· °''" ··· ······ ·························.