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APPLICATION FORM FOR ADMISSION TO - page 12 / 13

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ANNEXURE – III

MEDICAL CERTIFICATE (to be produced at the time of counseling)

Certified that I, Dr………………………………………………………………………………………..

(IMC. Reg.No. …………………………………….) have this ……………………………………….

day of ……………………………….2010 examined the candidate whose particulars are given below:

1. Name of the Candidate

:

2. Name of the parent

:

3. Sex

: Male / Female

4. Age with date of Birth

:

5. Identification Marks

1.

2.

6. Whether the candidate fulfils the following standards

:

Normal

Yes/No

ECG

Chest X-ray

Full Urine Test

(a) General Fitness consists of

Full Blood Test including HIV Test

Date

Month

Year

If No, specify the defect

  • ………

    years

Mental Retardness Test and

(b) Vision

: Yes/No

(c) Auditory functions

: Yes/No

(d) Speech functions

: Yes/No

Other General Tests

12

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