qg{S>Ho$Q>~H$ : YmZ H$m`mb` : _{Unmb

SyndicateBank: Head Office: Manipal

E_ Eg MS. 1415(EgQ>rE\$/STF.4)
gX^ g`m-nrS>r:EMAmaS>rS>r: EnrQ>rRef: PD:HRDD:APT:

{XZmH$/Date:

A`Wu mam VwV H$s OmZodmbr OmZH$mar

INFORMATION TO BE FURNISHED BY THE CANDIDATE

A`Wu H$m nyam Zm_/Name in Full

S>mH$ nVm/Postal Address

{nVm/n{V H$m Zm_/Fathers/Husbands Name

`m AmnH$m H$moB {ZH$Q> g~Yr j`, {gamo\w$m, JmD$Q>, {_aJr AWdm
C_mX go nr{S>V ahm h
Had you or any of your close relatives suffered from
consumption, Serofula, Gout, Epilepsy or Insanity

`m Amn H$^r {ZZ amoJm| go nr{S>V aho h AWdm AmnHo$ eara _| {ZZ
amoJm| Ho$ bjU nm`o J`o h
Have you at any time suffered from or had symptoms of
:

H$) YS>H$Z, _yN>m, CmoOZm

a) Palpitation, Fainting or any affection of the Heart

I) JwXm] _| gyOZ AWdm _yme` _| {dH$ma

b) Any affection of Kidney or Urinary Organs

J) AmV _| \$moS>m, Am_me` _| gyOZ, `H$V AWdm _bme` _| {dH$ma

c) Any affection of Stomach, Liver or Bowels

K) XwKQ>Zm, AWdm e` {M{H$gm

d) Any accident of surgical operations:

`m Amn Cn`w$ amoJ AWdm AdWVm Ho$ A{V[a$ {H$gr A`

`m{Y go nr{S>V h ?
Have you suffered from any other Disease or
illness of serious nature not mentioned above?

_ KmofUm H$aVm/H$aVr h {H$ Cn`w$ {ddaU _oar gdm}m_ OmZH$mar Ama {ddmg Ho$ AZwgma g` h & _Zo {H$gr Ano{jV
V` H$mo Zht {N>nm`m h & `{X _oao mam VwV Cn`w$ OmZH$mar PyR>r nm`r OmVr h Vmo Amn _oao {d C{MV H$madmB H$a
gH$Vo h &
I hereby declare that all the above statements are true to the best of my knowledge and belief.
I have not withheld any material information. In case any of the information furnished above
turns out to be false, appropriate action may be taken against me.

gmjr/Witness :

A`Wu Ho$ hVmja

Signature of the Candidate

Zm_ :/Name :
nVm :/Address :

qg{S>Ho$Q>~H$ : YmZ H$m`mb` : _{Unmb

SyndicateBank: Head Office: Manipal

gX^/Ref: nrS>r/PD: EMAmaS>rS>r/HRDD: EnrQ>r/APT:

{XZmH$/Date:

dWVm _mU n
MEDICAL FITNESS CERTIFICATE

(gaH$mar {g{db AnVmb `m mBdoQ> Z{gJ hmo_ go m {H$`m OmE)

(To be obtained from a Government Civil Hospital OR a Private Nursing Home)
1. A`Wu H$m Zm_ Ama nVm
Name and Address of the Candidate

2. D$MmB/Height
3. dOZ/Weight
4. qbJ/Sex
5. C_/Age

H$) {XImdQ> _|
a) By appearance

I) CgH$s {> R>rH$ h-hm/Zht

b) Is his/her vision Normal Yes/No
J) `{X Zht h, Vmo `m dh M_m nhZVm/nhZVr h-hm/Zht
c) If not does he/she wear spectacles Yes/No

K) `{X hm, Vmo bmg H$m nmda

d) If Yes The power of the Glass
6. `m dh {ZZ{b{IV amoJ go nr{S>V h /Wm/Wr?
Does he/she suffer/Has he/she suffered
from any of the following :
(H$) H$moB {MaH$mbrZ Ama gH$m_H$ amoJ go nr{S>V h /Wm
(a) Any Chronic & Contagious Disease
(I) dUmYVm-hm/Zht
(b) Colour Blindness Yes/No
(J) JyJmnZ Ama/`m ~hamnZ (~hamnZ Ho$ _m_bo _| VrdVm)
(c) Muteness and/or Deafness
In case of Deafness, the Degree
7. `m H$moB emar[aH$ {dH$bmJVm {XImB nS>Vr h, hm/Zht
Has he/she got any apparent physical
Defects Yes/No

H$) hmW
a) Upper Limbs

I) na
b) Lower Limbs

J) eara Ho$ A` AJ ({ddaU X|)

c)Any other part of the body
(with Details)

..2..
8.

Cn`w$ IS> 6 Ama 7 _| C{{IV Xmofm| (`{X H$moB hmoo)go

`m CgHo$ H$m_H$mO _| H$moB ~mYm hmo gH$Vr h ? - hm/Zht
Will any of the Defects (if any) as shown in the
Clause 6 and/or Clause 7 above, come in the
way of his/her normal functional life Yes/No

H$) {bIZm
a) Writing

I) ~mVMrV H$aZm
b) Conversing

J) nT>Zm
c) Reading

K) gmB{H$b MbmZm
d) Cycling

L>) nXb MbZm

e) Walking

M) gwZZm
f) Hearing
9.

N>mVr H$s _mn

Chest Measurement

H$) dmg ^aZo na

a) On full inspiration

I) dmg N>moS>Zo na
b) On full expiration

J) AVa
c) Difference
10.

nhMmZ {M

1.
2.

Identification Marks

H$) `h _m{UV {H$`m OmVm h {H$ emar[aH$ Ama _mZ{gH$ pW{V Ho$ AZwgma dh ~H$ _| godm H$aZo `mo` h &
a) Certified that he/she is Physically and mentally found fit to be employed in the Bank

I) `h _m{UV {H$`m OmVm h {H$ {ZZ{b{IV Xmofm| Ho$ H$maU dh ~H$ _| godm H$aZo hoVw A`mo` h &
b) Certified that he/she is found unfit to be employed in the Bank due to his/her following
defects :
1.
2.
3.

Am{X /etc.
WmZ /Place :
{XZmH$ /Date :

S>mQ>a Ho$ hVmja/Signature of the Doctor with

nOrH$aU g`m Ama _moha/Regn. Number &: Seal
Zm_/Name :
nVm/Address :