8/15/2019 3127_medical Check Up Form

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MEDICAL CHECK UP FORM

Certifcation by Examining Doctor

Please mark (X) in the appropriate box.

I certify that I have on this date examinedMr. / Ms. :

Passport No. : and found him/her:-

In good health

Having the following medical complications! please state!

"ndergoing treatment for: please state!

#ate :

$ignature of #octor:

Name of #octor :

%uali&cation :

Hospital / 'linic :

(egistration num)er :

*+cial stamp :

(emar,s )y "niversity :