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GP69 Sydney

This document is a medical examination form for candidates in the Republic of Xenya. It includes sections for personal information, medical history, and instructions for completion by both the candidate and the medical officer. The form must be filled out in duplicate and returned to the relevant ministry or department.

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danropa
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7 views2 pages

GP69 Sydney

This document is a medical examination form for candidates in the Republic of Xenya. It includes sections for personal information, medical history, and instructions for completion by both the candidate and the medical officer. The form must be filled out in duplicate and returned to the relevant ministry or department.

Uploaded by

danropa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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(To be completed in DUPLIGATE)

G.P.69

REPUBLIC OF XENYA

PART I

(Nane and address of MitrisEy/Departuent)

ro: rbe Medicar offi cer Lc .. A4..... 4/1.'..../...... Si]g"COUl{TY REIERRIL IIOSPITII
Name:.Mr'Miss/Mrs.-f- /AX.'.": /....h.l.i.l.'.,AD !. for medical examinaton as a
candidale for
(c.o.R- N.20 i this MAY zOM
Paft2
OF rtat EXAMINATION
I that I have this named candidate and that i. mv
for
Months (C.O-R- N20 (I)) as the Kef,ya
Covemment A&Dinistration-
... . . ..... Xas:/thE...... st"a"" &.... a(rtfl-/.4..u"ai"a om"*
.......... 3.+.,/K.............. zo .4S
Note6
Pdt I ofthe folE to b€ comptgted iD drplicale by tle o6cer serding lhe cadidate for examinaliotr-
Pat 2 ofthe fonn to bc completed by fte Medical offic€r, Irho will r€turn oae copy to &e
Ministry/Department which s€nl ihe catdidate.
Paticulars oo revers€ to be flled in by caitdidate befor€ appeeing fc Medical Examfuation-
tDelete whicheve. is i.applicable^
Cand;date's fi trame (iu BLOCL letteB) .... krf/fi"4
.t
The folowiry q[€stions to be etswered h,y the cedidare:
t have you €ver be€n an irrdi€Irt in hospital or nuning hone sufrering tolll ary dis€ale or injqz lf
so, give daris, stale na$rE ofdis€ase or i!irr.y, tttich hospital or nusing home. Nalne of doc6(s)
who lrEat€d you and wlrcths ar operalion B{s p€rfomed

2 Aport frmr aboue, have yo ever rEceired medical treeent f6 any $rious disease or injury? If
so, giYe p6riculars.

&"/r ,... -...........20 4-f

GPK

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