ABCDEFGHIJKLMNOPQRSTUVWXYZ
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MEDICAL CERTIFICATE
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For Employment
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I N S T R U C T I O N S
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1. This Medical certificate should be accomplished by a government physician.
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2. Attach this certificate to original appointments and reinstatements.
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FOR THE PROPOSED APPOINTEE
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NAME (Last, First, Middle, or if married woman, Maiden Name)
AGENCY/ADDRESS
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ADDRESS
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AGESEX
CIVIL STATUS
PROPOSED POSITION
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Pre-employment Medical-Physical Tests
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1. Blood Test
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2. Urinalysis
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3. Chest X-ray
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4. Drug Test
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5. Neuro-Psychiatric Examination (if necessary)
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NOTE: ALL RESULTS OF EXAMINATIONS MUST BE ATTACHED TO THIS FORM.
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FOR THE PHYSICIAN
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I hereby certify that I have personally examined the abovenamed
AFFIX
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individual and found her/him to be physically and medically fit/unfit
Documentary
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for employment
Stamp Here
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PRINTED NAME/SIGNATURE OF PHYSICIAN
CERTIFICATE NUMBER
OTHER INFORMATION ABOUT
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THE PROPOSED APPOINTEE
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OFFICIAL DESIGNATION
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AGENCYHEIGHTWEIGHTBLOOD
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(Bare feet)(Stripped)(Type)
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DATE EXAMINED
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FM-HRMO-05(EXT
0009-24-15
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