Form No.

IRD/REC-7

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INDIAN INSTITUTE OF TECHNOLOGY DELHI

cV J, x< n-110016
HAUZ KHAS, NEW DELHI -110016

+tMBE +xvx A BE ABEBE

INDUSTRIAL RESEARCH AND DEVELOPMENT UNIT

fpfdRlk LoLFkrk izek.ki=@Medical Fitness Certificate

+vBE BE x/Name of the official______________________________________________
{i/{i BE x/Fathers/Husbands name__________________________________________
{nx/Designation__________________________________________________________
+/Residence____________________________________________________________
Vx il/Date of Birth_______________________________________________________
{ u M< >S</Exact height by measurement___________________________________
{cSx BE A BBDiMi Sx/Personal marks for identification__________________________________
cBE BES (+.+x..)/AR (IRD)

+vBE/]{E BE ciF/Signature of Official/Staff

|hi BEi c BE x g/gi_____________________ V +.+x.. u Si {Vx

BE +vx xVx BE A |i c, BE |BE VS BE c + =x BE< M, BE Sx
n BE l, _______________ BE xc {< M< c* <xBE xBDi BE A <
+M xc xi c* <xBE +{x BElx A { nJ] BE +x <xBE + MM _______ c*

I do hereby certify that I have examined Shri/Smt._______________________a candidate for employment

under IRD operated project and cannot discover that he/she has any disease, constitutional afflication, or
bodily infirmity, except___________.I do not consider this a disqualification for employment. His/Her age
is, according to her/his own statement, and by appearance about___________________________years.

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Left hand thumb and finger impression.
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Fourth or small finger

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Third finger

Second finger

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First finger

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Thumb

V +vBE BE F =M BE U{ A MA, =xBE x/Taken before Name of Officer

{nx/Designation of Officer
nxBE/Date

|i BE BElx il Ph
CANDIDATES STATEMENT AND DECLARATION

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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)

{ x ({] +F )_________________________________________________

2)

+ A Vx lx ___________________________________________________

3)

(+) BD +{ BE SSBE, +x V, Oxl r +l {i (n {x), lBE Jx

+x, n, n M, {E{E BE M, U, c]V, A{xbb<] M {i c c ?_______

Name in full (in block letters)

Age and Place of Birth

(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.

+{BE {U ]BE BE M M ?/When were you last vaccinated?______________

5.

BD +{ +{BE BE< xBE]i xv BE F, BEh~, M>], n, n, M =xn

M {i c c ?________________________________________________

Have you or any of your near relations been afflicted with consumption, scrofula, gout, asthma,
fats, epilepsy or insanity ?_________________________________________________________

7.

BD +{x BE +vBE BE +x BE BEh BE |BE BE Pc] =kVx c BE c ?

Have you suffered from any form of nervousness due to overwork or any other cause ?______

BD {U 3 BE SBEi +vBE, SBEi b u BE xBE i

l xBE BE A +{BE SBEi {F BE M< + +{BE +M Pi BE M c ?

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.

+{x { vi h nVA/Furnish the following particulars concerning your family:-

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c A l li

Fathers age if living &

state of health

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c A l li
Mothers age if living &
state of health

i BE {i BE + +
i BE BEh/Fathers age at
death & cause of death

i BE i BE + +
i BE BEh/Mothers age at
death & cause of death

Vi < BE J,
=xBE + + l
li/No. of brothers living,

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=xBE + il i BE BEh

their age & state of health

No. of brothers dead, their age at

death & cause of death

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+ + l li

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=xBE + il i BE BEh

No. of sisters living, their age

& state of health

No. of sisters dead, their age at

death & cause of death

Ph BEi c BE Z Vc iBE {i c + c ={BDi =k c c*

I declare that all the answers given above to the best of my knowledge and belief are to be true and correct.

i x~ BEci c BE x M +x BE li +Mi |h{j BE +v { {x xc

c*

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___
]{{h: ={BDi BElx BE ii BE A |i =kn cM* VxZ BE BE Sx BE U{x c
+{x xBDi BE VJ bM + xBDi cx BE li ={nx BE +vi k = Si BE
n VAM*

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

|hi BE Vi c BE g/gi/g____________________________ {j/{ix/{j

g_____________BE {U_____ Vxi c + Vc iBE {i c + c <xBE xiBE
Sj +SU c + <xBE {k A xc c V +.+x.. u Si {Vx xBDi BE A <xc
+x{BDi ~ci c*

Certified that I have known Shri/Smt./Miss____________________________son/wife/daughter of

Shri____________________for the last_____________years and to the best of my knowledge and belief
he/she bears a good moral character and has no antecedents which render him/her unsuitable for the
employment under the IRD operated projects.

g/Shri gi/Smt.g/Miss____________________ / v xc c*/is not related to me.

lx/PLACE____________________________ ciF/SIGNATURE______________________
nxBE/DATED________________________________ x/NAME:______________________________
{nx/DESIGNATION______________________
(* |h nx +vBE BE BE ix |i BE BBDiMi { Vxi c*)
(The certifying Officer should have personally, known the candidate for at least three years)
{]/ANNEXURE-III
_______________________ {l i c/ix~ {BE |iY BEi c/BEi c BE i A

i vx l{i BExx BE |i SS x~ A {En JM/JM, i BE |i A +Jhbi

BE xA JM/JM + { x~, <xn A x{Fi BE l +{x BEiB BE {x BEM/BEM
(< nn BE*)

I___________________________________swear/solemnly affirm that I will be faithful and bear true

allegiance to India and to the Constitution of India as by law established, that I will uphold the sovereignty
and integrity of India and that I will carry out the duties of my office loyally, honestly and with impartiality
(So help me God).

nxBE/Dated______________

ciF/Signature ____________________
x/Name______________________________
{nx/Designation ___________________
M/BExp/+xM/ABEBE/Deptt/Centre/Section/Unit