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This form is to be used by every and who date is require by the Andhra Pradesh public service
commission to produce certificate of physical fitness it must be signed by a commissioner
medical officer or a civil medical officer or rank not lower then that of a civil surgen A district
medical officer employes under Andhra Pradesh government

Note :A candidate outside the Andhra Pradesh state whose unable produce the certificate from
medical officer employed in Andhra Pradesh state may be produce it from a medical office of a
corresponding rank out side the A.P. state such certificate should containing the following

1. The state under which the medical officer is employed and the name of the institution in
which as employed and his rank

2. Register number of certificating medical officer in the register in which his name has
been registered

3. The official stamp of the institution on which the certificating medical officer is
employed the certificates produce will be subject to acceptance after security by the
director of medical service Andhra Pradesh

Name and Rank of officer granting the certificate

A candidate for employement under the Govt of A.P
The service
and can not dieco that he has and desease communicable or other wise constitutional or body
infirmity except do not cosides disqualification for the employement he seeks

I do further certify that in my opinion his general physical condition is such as to unable him
erforin efficiently the active duties of executive service

His age according to his own statement year

and appearance about year
small pox
I also cerify that he marks or
On full inspiration
Chief measurement in his on full expiration
Difference (experience)
height if in
weight in Lb
hisxision is normal

hyper metropic

(here enter the degree of and defect the strength correction glasses)

Myopiei (
(here enter the degree of and defect strength of correction glasses) aring is normal
defective (Much or slight )
Does chemical examination shown (i) albument (ii) sager state state specific gravity
personal make at last show should be mentioned


DATE Designation
The candidate must make the statement required below prior to his medical examination and
must sign the declaration append there to the presence medical office his attention is specially
directed to the warin contained in the note below

1. state your name in full

2. state your age and birthplace
3 . (a) have you every had small pox intermittent or any
other favour enlargent or suppuration or glands.
Speetting of blue asthma infiamamation of lungs.
Heart disease fainting attacks the umainsum, appendicitle.
(b) We any other disease or accident recring confinement
To had medical or surgical treatment
(c ) suffered from any illness wound or is jusies sustained
While on active service during the war of 1932,191
4. when were laft unceieed ?
5. have you or any of your near relations been affected with
consumption scretfuls goats
astama fits epilepsy crinsanity?
6. have you sufted from any from of norvouiness but to
over work as any other cause.
7. have you been examined and declared unfit for government
Service by a medical office/medical board within the last three
Years ?
(to be filled only in the cases of candidates for subordinate service)
8 .furnished the following particulars concerning your
Fathers age in Father’s age at Number of Number of Mother’s age if Mother’s age at Number of number of sister
living and stare death and cause brothers leaving brother’s death living and stage Death and cause Sister living death their age
of health of death their age &stage their ages of health of death their ages and at and cause of
of death At and cause of state of health death

I declare all than answer to be to the best of my belief true and corect
I also truly affirm that I have not received at disability certificate / person on
Candidate signature
Signature in presence
Signature of medical officer
Note 1. the candidate will be held resports belrs the accurancy of the above statement by willfully
appearing any information he will into the rank of loosing the appointment and of appointed of
for set in all claims to supervation allowance of graduty
2 .the candidate selected by commissions for direct retirement to the Andhra Pradesh police
service of recurired to Andhra Pradesh civil executive branch other wise than from Andhra
Pradesh revenue subordinate service will be examined a medical board before appointment