CANDIDATES STATEMENT AND DECLARATION
The candidate must make the statement required below prior to his medical examination and must
sign the declaration appended there to. His/her attention is specially directed to the warning contained in
the Note below :-
1. State your name in full (In block letters) ____________________________________
2. State your age and place of birth __________________________________________
3.
(a) Have you ever had smallpox, intermittent
or any other fever, enlargement or
suppuration of glands, spitting of blood,
asthma, heart disease, lung disease,
fainting attacks, rheumatism, appendicits ?
or
(b) Any other disease or accident requiring
confinement to bed and medical or
surgical treatment
4. When were you last vaccinated ?
5.
Have you or any of your near relations been
afflicated with Consumption, scrofula, gour,
asthma, fits, epilepsy or insanity ?
6.
Have you suffered from any form of nervousness
due to Overwork or any other causes ?
7.
Have you been examined and declared fit for
Government Service by a Medical Officer/Medical
Board, within the Last three years
8. Furnish the following particulars concerning your family :-
Father’s age If living & Father’s age at death No. of brothers living, No. of brothers dead
state of health and cause of death their ages & state of their ages at death &
health cause of death
Mother’s age If living & Mother’s age at death No. of sisters living, No. of sisters dead their
state of health and cause of death their ages & state of ages at death & cause of
health death
I declare all the above answers to be to the best of my belief, true and correct.
I also solemnly affirm that I have not received disability certificate/Pension on account of any disease or
other condition.
Candidate’s Signature _________________________________
Signed in my presence _________________________________
Signature of Medical Officer ____________________________
Note : The candidate shall be held responsible for the accuracy of the above statement, by willfully suppressing any
information he will incure the risk of losing the appointment, if appointed, or forfeiting all claim to superannuation
allowance or gratuity.
MEDICAL CERTIFICATE UNDER ARTICLE 49 CIVIL SERVICE
REGULATION
I do hereby certify that I have examined _______________________________________ a
candidate for employment in the Indian Audit & Account Department and cannot discover that he has
any disease, constitutional affection or bodily infirmity except ________________________ I (consider)
do not consider this a disqualification for employment in the office of the Accountant General (Audit),
Bihar, Patna. His age is, according to his own statement, ________ and by appearance about
________years.
Medical Officer
Place : _________________
Date : _________________
DECLARATION BY CANDIDATE
I ____________________________________ a candidate for employment in the office of the
Accountant General (Audit), Bihar, Patna within Indian Audit & Account Department, do hereby declare
that I have not at any time been pronounced unfit for Government employment by the Medical Board or
any other duly constituted medical authority.
Signature of Candidate