Medical Certificate for Gazetted Officer

Statement of the case of

Name: Appointment: Age: Total Service: Previous periods of leave if absence on medical certificate: Habits: Disease:

I, Autorised Medical Attendant of after careful personal examination of the case certify that is in bad state of health and I solemnly and sincerely declare that according to the best of my judgment the period of absence from duty is essentially necessary for the recovery of his health and recommend that he may be granted leave with effect from . In my opinion it is / is not necessary for the officer to appear before a Medical Board.

Signature:

Signature Of Government Servant

Name:

Designation:

Department:

Place:

Dated:

Signature of Authorised Medical Attendant with seal and Registration Number