Signatufe of Candidate

I do hereby

certify that I have examined

a candidate

for employment in the

Paste photograph here

Department and cannot discover that he/she has any disease,

constitutional affection or bodily infirmity except
Photo attested

I do not consider this as a disqualification

for employment in

the Office of ..............

His/her age according to his/her own statement is

........ years and by appeamnce about

years. He/she has a small pox/ vaccination mark.

Personal marks of identification

Thumb lmpression attested
1)

2l

Signature

Name:

Seal

Rei No.

Rank:
Designation
Station

Date: