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(¡ºà̾) ...........................................................................
[¡. Àè. Â./ P. T. O.]
 General 169
[To be filled up by the Candidate and handed over to the Medical Officer]

Declaration by candidate provisionally selected for appointment in the .....................................................

................................................................................................................. Department as
Candidate for appointment under Government should complete the form below and hand it to the Government Medical
Officer at the time of examination.
The candidate will be held responsible for the accuracy of the statements hereon, and by wilfully suppressing any information he will incur the
risk of loosing the appointment.

Name in full : ..........................................................................................................................................................................................................

Address : .................................................................................................................................................................................................................

Occupation : ...........................................................................................................................................................................................................

Date of birth : ......................................................................................................... Age on next birthday : ...........................................................

Place of birth : ........................................................................................................ Whether married or single : ....................................................

Have you been successfully vaccinated ? ..................................................................................................................................................................

If so, give last date : .........................................................................................................

Have you had smallpox ? ................................................................................................................................

Have you suffered from habitual cough, spitting or coughing blood, pleurisy, or any complaint of the lungs ? .....................................................................

Have you suffered from rupture, piles, rheumatism, epileptic or other fits, insanity, or from any nervous complaint ? ............................................

................................................................................................................................................................................................................................

Have you suffered from any other desease or from serious personal injury ? ....................................................................................................................

Have you any deformity, congenital or acquired ? ....................................................................................................................................................

Have you ever undergone any surgical operation ? If so, give particulars and dates : ...............................................................................................

.............................................................................................................................................................................................................................................

Are you now in good health ? ..................................................................................................................................................

Are you temperate in your habits ? ..........................................................................................................................................

Are any members of your family or near relatives, or have they been, subject to consumption or any disease of the lungs, or to insanity

or fits ? ...............................................................................................................................................
Father’s Age, if living and Father’s Age, at Death, and Mother’s Age, if living and Mother’s Age, at Death, and
State of Health Cause of Death State of Health Cause of Death

No. of Brothers living, and No. of Brothers Dead, their No. of Sisters living, and No. of Sisters Dead, their Ages at,
their Ages Ages at, and Cause of Death their Ages and Cause of Death

I do hereby declare that the answers given by me on this form are true and that I have not suppressed any material facts.

(Signature) ...........................................................................
H - 022255 (2004/10) Êòé Èâ¨å Ç°ïÆà Äê÷¸ ï¼ÀåںàºëÉ