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Documente Profesional
Documente Cultură
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INDIAN INSTITUTE OF TECHNOLOGY DELHI
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HAUZ KHAS, NEW DELHI -110016
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Left hand thumb and finger impression.
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CANDIDATES STATEMENT AND DECLARATION
The candidate must make the statement required below prior to Medical Examination and must sign, the
declaration appended thereto. Attention is specially directed to the warning contained in the Note below.
1)
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2)
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3)
(a) Have you ever had small pox, intermittent or any other fever, enlargement or suppuration of
glands, spitting of blood, Asthma, hear disease, lung disease, fainting attacks, rheumatism,
appendicitis ?_________________.
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Vi c c c ? ________________
(b) Any other disease or accident requiring confinement to bed and medical or surgical
treatment._____________________________.
4.
5.
Have you or any of your near relations been afflicted with consumption, scrofula, gout, asthma,
fats, epilepsy or insanity ?_________________________________________________________
7.
Have you suffered from any form of nervousness due to overwork or any other cause ?______
Have you been examined and declared unfit for Government service or service in an autonomous
body by a Medical Officer, Medical Board within the last three years ?
_________________________________________________________________________________
_________________________________________________________________________________
8.
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Mothers age if living &
state of health
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death & cause of death
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death & cause of death
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I declare that all the answers given above to the best of my knowledge and belief are to be true and correct.
I also solemnly affirm that I have not received a disability certificate pensions on account of any disease or
other conditions.
|l BE ciF/Candidates Signature__________________
={li ciF BE/Signed in my presence________
SBEi +vBE BE ciF/Signature of Medical Officer___
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NOTE: The candidate will be held responsible for the accuracy of the above statement. By willfully
supressing any information, he will incur the risk of losing the appointment and if appointed forefeiting all
claim to superannuation allowance of gratuity.
Sj |h{j/CHARACTER CERTIFICATE *
{]/ANNEXURE-II
nxBE/Dated______________
ciF/Signature ____________________
x/Name______________________________
{nx/Designation ___________________
M/BExp/+xM/ABEBE/Deptt/Centre/Section/Unit