PRE-EMPLOYMENT

eLARSEN & TOUBRO FITNESS CERTIFICATE

C Name
A Date of Birth: Age Blood Group'
N
D Sex : Male 0 Female0 I Marital Status: Married 0 Unmarried 0
Address
D
A
Any allergy / Disability / Pre - existing disease:
E
Date' Signature of Candidate

C
Height Weight Near L.E. R. E.... ....... ... Hearing
N Cms. Kgs. Vision: Distant L.E RE — Left Ear
Colour Vision__ Right Ear
A
L BP: Pulse Rate: Resp. Rate:

N CVS: RS: Abdomen:

N Any other Findings:

G
S

N
V CBC - Hb gm% TLC / cumm% DLC -P L E M
E BLOOD
T FBS mg% BUN mg% Creatinine mg%

A URINE Routine:
T
0N X-Ray Chest: ECG:
N

C I Dr
E
R hereby certify that I have examined Mr /Ms •
T.. . .............. . . .and find him FIT / UNFIT for employment.
F Remarks if unfit-

C
A

E Signature & Seal Reg. No. Address /Tel No.

O I declare that the above information is true and correct to the best of my knowledge and I am not suffering
E from any disease / illness, the presence of which I have not revealed. I fully understand that any
C
L misrepresentation of this declaration could lead to the termination of my offer / appointment. In case of any
A discrepancy arising out of my declaration, I will undergo the medical check-up by the company's suggested
R doctor and their findings will be fully binding on me and action thereon towards my employment will be
A accepted by me. I give my consent to L&T to seek further information, if any, from me directly or from any
T
appropriate doctor.
0
N Signature of Candidate: Date:

p msnon To be signed by a doctor with minimum M.B.B.S. Qualification P.T.O.
Any additional information-

Recommendation by Doctor

Remarks by Doctor: