TAMILNADU ELECTRICITY BOARD

(CERTIFICATE OF PHYSICAL FITNESS (FOR CLASS III / IV SERVICE) (This form is to be used by every candidate who is required by the Tamilnadu Electricity Board to produce the certificate of physical fitness. It must be signed by a Medical Officer of ran not lower than that of an !sst."urgeon# employed under the $overnment of Tamilnadu or by an %onorary !sst."urgeon and &hysician appointed by the $overnment of Tamilnadu to a $overnment Medical Institution'. (OTE) ! candidates who resides outside Tamilnadu and who is unable to produce the medical certificate from a medical officer employed in Tamilnadu may produce it from a medical officer of corresponding ran out side Tamilnadu. "uch certificate should contain the following particulars. *. The state under which the medical officer is employed and the name of the institution in which he is employed and his ran . +. ,egister number of the certifying medical register in which his name has been registered. officer in the

-. The official stamp seal of the institution in which the certifying medic al officer is employed. The certificates so produced will be sub.ect to acceptance after scrutiny by the /irector of Medical service# Tamilnadu.

NAME AND RANK OF OFFICER GRANTING THE CERTIFICATE0

I do hereby certify that I have e1amined (2344 (!ME' 5555555555555555555555555555 a candidate for employment under the Tamilnadu Electricity Board in the 55555555555555555555555555555555 555555555555555555555555555 "ervice as 55555555555555555555. and cannot discover that he has any disease communicable or otherwise# constitutional affection or bodily in firmity e1cept that his weight is (in e1cess of6below' 55555555555 that standard prescribed or e1cept 555555555555555. I do 6 do not consider this a disqualification for the employment he see s. ...2...

6+6 I do further certify that in my opinion his general physical condition is such as to enable him to perform efficiently the active duties of e1ecutive services. %is age is according his own statement 555555 years and by appearance about 555555555 years. I also certify that he has mar s of smallpo16vaccination. 7hest measurement in cms. (On full inspiration' (On full e1piration' (/ifference e1pansion' Blood &ressure) "ystolic) /iastolic)

%eight in cms55555 8eight in 9gs55555

HIS VISION IS NORMAL;

%ypermetropic (555555555555555555555555555555555555555555555555' %ere enter the degree of defect strength ofcorrection glasses'

and

Myopic

(555555555555555555555555555555555555555555555555' %ere enter the degree of defect and strength of correction glasses'

!stigmatic ("imple or (555555555555555555555555555555555' ' %ere enter the degree of defect and strength ofcorrection glasses'

mi1ed'

%earing is normal6defective (much or slight' 3rine :does chemical e1amination so (*' !lbumin. (+' "ugar "tate specific gravity)

&E,"O(!4 M!,9" (at least two should be mentioned') *'

+'

"tation) "ignature) /ate) 55555555555555555555

55555555555555555555

,an ) /esignation)

6-6 CANDITATES STATEMENT AND DECLARATION The candidate must ma e the statement required below prior to his Medical E1amination and must sign the declaration appended therein. %is attention is specifically directed to the warning contained in the note below); *' "tate your name in full (in bloc letters')

+' "tate your age and place of birth

-' !' %ave you ever had small po1# Intermittent or any other fever. Enlargement or suppuration of $lands. "pitting of blood# asthma# %eart disease# lung diseases# 2ainting attac s# rheumatism# !ppendicitis< (or' b' !ny other disease or accident ,equiring confinement to bed and Medical or surgical treatment< c' "uffered from any illness# wound or In.uries sustained while on active "ervice during the war of *=-=;*=>?<

>' 8hen were you last vaccinated<

@' %ave you or any of your near relations been affected with consumption# scrofula# gout# !sthma# fits# epilepsy or insanity< ?' %ave you suffered from any form of< (ervousness due to over wor or any

Other causes<

A' %ave you been e1amined and declared unfit for $overnment "ervice by a Medical Officer6 Medical Board# within the last three years<

B' 2urnish the following particulars 7oncerning your 2amily 2atherCs age if living and state of health 2atherCs (o. of(o. ofMotherCs MotherCs (o. of(o. of age abrothers brothers age ifage asisters sisters death andliving dead# living anddeath andliving dead# cause oftheir agestheir state ofcause oftheir their death and stateages# athealth death ages andages# at of helth and cause state ofand cause of death helth of death

*. I declare all the above answers to b# to the best of my belief# true and correct. +. I also solemnly affirm that I have not received a disability certificate 6&ension on account of my disease or other condition.

"igned in my presence.

"ignature of Medical Officer

7andidateCs "ignature.

(ote0 The candidate will be held responsible for the accuracy of the above statement. By willfully suppressing any information# he will incur the ris losing the appointment and# if appointed# of forfeiting all claims to superannuation allowance or $ratuity.

A N N E X U R E 1) Distance vision without glasses (each eye separately) 2) Distance vision with glasses (each eye separately) ) !he a"ount of hyper"atropia # "yopia or astig"atic $efect an$ strength of correction glasses use$ %) Near vision (each eye separately) &) 'hether suffering fro" s(uint or any "or)i$ con$ition of the eyes or of eye li$s (!racho"a*li+e) of either eye ,) Each eye # fiel$ of vision -) Each eye# colour vision .) /) Each eye# fun$us appearance 0tan$ar$ of vision :

: :

: : : :

11) 2aving regar$ to his vision whether 33333333333333333333333333333333333333 (Na"e of 4an$i$ate to )e specifie$ ) is or is not Appoint"ent as 33333333333333
(post to )e specifie$)5