Application for the (Grant or Renewal) of: (Please Tick whichever is applicable)
| S.No. | Employer's Name | Date of Commencement | Date of Termination | Total Period of service |
|---|---|---|---|---|
| 1 | ||||
| 2 |
| Institute/School | Degree/Certificate | Period of Education | Score (%) | Training Details (Firm Name) | Duration of Training |
|---|---|---|---|---|---|
I hereby declare that I am medically fit to undertake Electrical work, as stated in the Medical Certificate issued by (Name of Doctor) working in (Name of Hospital/Dispensary) as (Position).
I hereby declare that application is accompanied with the document as specified under sub-rule (2) of rule (10) of the Rajasthan Electrical Inspectorate (Formation of Technical Committee and Grant of Licence, Competency to work and permit to work) Rules, 2016.
I do hereby declare that the particulars given above are correct.
Signature
[To be filled in by a registered medical practitioner]
(a) Does the applicant, to the best of your judgment, suffer from any defect of vision? If so, has it been corrected by suitable spectacles.
(b) Can the applicant, to the best of your judgment, readily distinguish the pigmentary colours, red and green?
(c) In your opinion, does the applicant suffer from a degree of deafness which would prevent hearing the ordinary sound signals?
(d) In your opinion, does the applicant suffer from night blindness?
(e) Has the applicant any defect or deformity or loss of member which would interfere with the efficient performance of his duties?
(f) Optional: (i) Blood group: (ii) RH factor:
I have personally examined the applicant Shri/ Smt./Kum. and certify that:
And, therefore I certify that to the best of my judgment:
Signature or thumb impression of the candidate
Signature of Medical Officer/Practitioner (Seal)