Certificate of Physical Fitness

CERTIFICATE OF PHYSICAL FITNESS This form is to be used by every and who date is require by the Andhra Pradesh public service commission to produce certificate of physical fitness it must be signed by a commissioner medical officer or a civil medical officer or rank not lower then that of a civil surgen A district medical officer employes under Andhra Pradesh government Note :A candidate outside the Andhra Pradesh state whose unable produce the certificate from medical officer employed in Andhra Pradesh state may be produce it from a medical office of a corresponding rank out side the A.P. state such certificate should containing the following particulars.

1. The state under which the medical officer is employed and the name of the institution in which as employed and his rank 2. Register number of certificating medical officer in the register in which his name has been registered 3. The official stamp of the institution on which the certificating medical officer is employed the certificates produce will be subject to acceptance after security by the director of medical service Andhra Pradesh Name and Rank of officer granting the certificate A candidate for employement under the Govt of A.P The service and can not dieco that he has and desease communicable or other wise constitutional or body infirmity except do not cosides disqualification for the employement he seeks I do further certify that in my opinion his general physical condition is such as to unable him erforin efficiently the active duties of executive service His age according to his own statement and appearance about year small pox I also cerify that he marks or Vaccination On full inspiration Chief measurement in his on full expiration Difference (experience) height if in weight in Lb hisxision is normal

year

hyper metropic (here enter the degree of and defect the strength correction glasses) Myopiei ( (here enter the degree of and defect strength of correction glasses) aring is normal defective (Much or slight ) Does chemical examination shown (i) albument (ii) sager state state specific gravity personal make at last show should be mentioned

STATION DATE

signature rank Designation

The candidate must make the statement required below prior to his medical examination and must sign the declaration append there to the presence medical office his attention is specially directed to the warin contained in the note below 1. state your name in full 2. state your age and birthplace 3 . (a) have you every had small pox intermittent or any other favour enlargent or suppuration or glands. Speetting of blue asthma infiamamation of lungs. Heart disease fainting attacks the umainsum, appendicitle. (or) (b) We any other disease or accident recring confinement To had medical or surgical treatment (c ) suffered from any illness wound or is jusies sustained While on active service during the war of 1932,191 4. when were laft unceieed ? 5. have you or any of your near relations been affected with consumption scretfuls goats astama fits epilepsy crinsanity? 6. have you sufted from any from of norvouiness but to over work as any other cause. 7. have you been examined and declared unfit for government Service by a medical office/medical board within the last three Years ? (to be filled only in the cases of candidates for subordinate service) 8 .furnished the following particulars concerning your Family Fathers age in living and stare of health

Father’s age at death and cause of death

Number of brothers leaving their age &stage of death

Number of brother’s death their ages At and cause of death

Mother’s age if living and stage of health

Mother’s age at Death and cause of death

Number of Sister living their ages and state of health

I declare all than answer to be to the best of my belief true and corect I also truly affirm that I have not received at disability certificate / person on Candidate signature Signature in presence Signature of medical officer Note 1. the candidate will be held resports belrs the accurancy of the above statement by willfully appearing any information he will into the rank of loosing the appointment and of appointed of for set in all claims to supervation allowance of graduty 2 .the candidate selected by commissions for direct retirement to the Andhra Pradesh police service of recurired to Andhra Pradesh civil executive branch other wise than from Andhra Pradesh revenue subordinate service will be examined a medical board before appointment

number of sister death their age at and cause of death