CSC FORM NO.

211 (1997) PHILIPPINE CIVIL SERVICE

MEDICAL CERTIFICATE
For Employment
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INSTRUCTIONS

1. This medical certificate should be accomplished by a government physician.

2. Attached this certificate to original appointment and reinstatements.
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FOR THE PROPOSED APPOINTEE

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NAME : (Last, First Middle Name(If married full maiden name) AGENCY

ACOB, AMERA ESMAIL DepEd

PIKIT SOUTH
ADDRESS: PROPOSED
POSITION
RAJAH MUDA , PIKIT, COTABATOCALAWAG, PIKIT, COTABATO
TEACHER I
AGE SEX CIVIL STATUS

23 FEMALE SINGLE

PRE-EMPLOYMENT MEDICAL-PHYSICAL TESTS

1. Blood Test
2. Urinalysis
3. Chest X-Ray
4. Drug Test
5. Neuro-Psychiatric Exam.

NOTE: ALL RESULTS OF EXAMINATION MUST BE ATTACHED TO THIS FORM

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FOR THE PHYSICIAN

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AFFIX
I HEREBY CERTIFY that I personally examined the above-named
individual and found her/him to be physically and medically fit and unfit for Documentary Stamp
employment.
SIGNATURE OF PHYSICIAN CERTIFICATE NUMBER OTHER INFORMATION ABOUT
THE APPOINTEE

OFFICIAL DESIGNATION HEIGHT(Bare Feet) WEIGHT(Stripped)

5' 50 kgs.

AGENCY DATE EXAMINED

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