Form 'A' - Application For Certificate Of Competency As Boiler Attendant Class

Form 'A' - Application For Certificate Of Competency As Boiler Attendant Class - Ii Page 5

(Annexure-1)

CERTIFICATE OF PHYSICAL FITNESS

I, do here by certif. that I have examined (Full name) Sri…………………………………………..

S/o………………………………………..a candidate for Boiler Attendant I/II Class and cannot discover that he

has any physical deformity or blindness of one or both eyes or deafness or stammering or other defect of

speech.

I further certify that I connot discover that he has any disease communicable or otherwise

constitutional affection of bodily infirmity except his weight is in Excess / Below of the standards, or except

…………………..……….

I do not consider this a disqualification to perform duties of boiler Attendant.

I do further certify that is my opinion general physical condition in such as to enable him perform

efficiently the active duties of Boiler Attendant.

His age is according to his own statement ……………………………… years and by appearance about

……………………………years. I also certify that he has marks Small pox / Vaccination.

I further certify that the candidate has affixed his signature below in my presence.

Signature of the Candidate

Or thumb impression……………………………..

PERSONNEL DESCRIPTION OF APPLICANT

Height

cms

Weight

kgs

Complexion

Colour of hair

Colour of eyes

Personal Marks

Station:

Signature:

Date:

Name:

Designation:

Note: The above certificate shall be issued by a Registered Medical practitioner of atleast M.B.B.S.

qualification of a civil Medical Officer of rank

not lower than a Assistant Civil Surgeon.

Form 'A' - Application For Certificate Of Competency As Boiler Attendant Class - Ii Page 5