Central University of Orissa, Koraput
(Established Under the Central Universities Act, 2009)
MEDICAL DECLARATION FORM
ADMISSIONS – 2013-2014
Name :
Father’s Name :
Mother’s Name :
Date of Birth :
Programme :
Subject : Date, Month and Year of Admission :
A. Please mark each response individually
Affix latest Passport Size Photograph here and sign across the photograph Are you suffering or have you in the past suffered from any of the following:
1. Epilepsy (First) : YES / NO
2. Psychiatric (Mental) Disturbances : YES / NO
3. Other Contagious Diseases : YES / NO
B. Are you under treatment or have you in the past taken treatment for any disease or disorder for a period of three months or longer? YES / NO If "YES", please give details Disease : Medicines taken :
C. Blood Group :
D. Did you suffer from any physical disability? YES / NO
If "YES" please give details DECLARATION BY THE STUDENT I hereby declare that the information provided above is correct to the best of my knowledge. I am aware that wilful suppression or misrepresentation of information will lead to cancellation of my admission at any stage of my stay in the University. Place: Date: Signature of the student CERTIFICATE Height: Weight: Age:
I have examined Shri/Kum. S/o/D/o and found him/her medically fit to pursue higher studies in the Central University of Orissa. He/she is not suffering from any contagious disease. Date: Office Seal: (Asst. Civil Surgeon) Place: (Government Hospital)