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MEDICAL CERTIFICATE OF FITNESS

Important Instructions: 1. The Candidate must ensure that a legally qualified and registered medical practitioner with minimum M.B.B.S. completes this form. Additional sheets may be attached if more space is required. 2. The candidate is responsible for any costs associated with the preparation of this report. 3. Please hand over the complete form to your local HR at the time of joining. qualification as

SECTION - 1 (to be filled by the Candidate) Candidates Personal Details


Name Gender Date of birth Contact No. (Mobile)
first name middle name last name paste a passport size color photograph attested by your consulting doctor

Male
DD / MM /

Female
YYYY

Blood Group: (Resi.)

Candidate's Statement
Do you have any congenital defect/abnormality? Yes No. (If yes, provide details)

Do you have any physical deformity/handicap or use any mechanical/physical assistance for mobility? Yes No. (If yes, provide details)

Have you had any form of serious illness or operation in the last two years? Yes No. (If yes, provide date and details of surgery)

Have you been treated/hospitalized for cancer/Tumor/Cyst or any other growth? Yes No. (If yes, provide details)

Has medical grounds been a reason for un-employment or you not performing a specific role in the past? Yes No. (If yes, provide details)

Have you ever suffered or suffering from any of the following? High/Low Blood Pressure Arthritis Tuberculosis Thyroid Ailment Stroke Peptic Ulcer Epilepsy Heart attack Bronchitis Heart Disease Glaucoma Slipped disc Diabetes/Hypoglycemia VD Tests Positive Color Blindness Liver disease Asthma

Have you ever suffered or suffering from any other illness or impairment not mentioned above? Yes No. (If yes, provide details)

Are you presently in a medical condition (including pregnancy) that may require you to be away from work in the next 12 months? Yes No. (If yes, provide details)

Candidate's Declaration
I declare that to the best of my knowledge, the answers to the questions in this form are correct and that I am not suffering from any disease/illness, the presence of which I have not revealed. I fully understand that any misrepresentation of this declaration could lead to the termination of my offer/appointment. I have no objection to CMC Ltd. seeking further information either directly from me or from my Consulting doctor or other appropriate doctor. In case of any discrepancy arising out of my declaration, I will be undergoing the medical check-up by the Companys suggested medical clinic/doctor and their findings will be fully binding on me and any action thereon towards my employment will be accepted by me.

Signature

Date

Section - 2 (to be filled by the Medical Practitioner) Medical Practitioners Details


Full name (as listed on the applicable State registry) Registration ID: Postal Address:

Contact Number (Day time)

General Examination
Body wt: Pulse: Kgs /min. Height: BP: cms. mm Hg

Declaration
I certify that I have carefully examined Mr/Ms Son/Daughter of

S/HE IS MEDICALLY

FIT

UNFIT

for employment with CMC Ltd.

Remarks:

Signature

Seal

Date

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