Professional Documents
Culture Documents
First Name:
Middle Name:
Companys Name:
Employee Code :
PASTE YOUR
RECENT
PASSPORT
SIZE
PHOTOGRAPH
Last Name:
Sr. No.:
Department:
Designation:
Declaration
I declare that the undersaid information is true and correct to the best of my knowledge.
If any of this information is found to be false / incomplete / incorrect the company can
cancel my appointment or terminate my service contract. No legal implications
regarding the same will be borne by Bureau Veritas (India) Pvt Ltd or
Bureau Veritas Certification (India) Pvt Ltd.
Date:
Thumb Impression / Signature of the candidate
Personal History
1. Smoking: ______________ Quantity:
2. Alcohol:
_________
3. Tobacco /Gutkha:
Regular:
Quantity:
4.Any Other:
8. Tea /
9. Vasectomy:____________________________
10. Any Allergies (Including
Drugs):_________________________________________________
Health History
Any Present Complains: _____________________________________________________
H/O Hypertension/Diabetes Mellitus/Heart Disease/Epilepsy :
______________________
Any other significant past illness: ______________________________________________
Any Accidents in past: _______________________________________________________
Any Surgical Intervention:____________________________________________________
General Examination
Physical Parameters :
Height :
Weight :
Physical Deformities :
Conjunctiva : Pallor / Icterus :
Nail : Pallor / Icterus / Clubbing :
Edema : Pedal / Facial / Generalized :
Nodes / Glands / Thyroid :
2. Heart Rate :
4. B.P. :
5. Heart beat-location :
3. Rhythm :
RS (Respiratory System)
1.Shape of Chest :
3. RR :
4. Air Entry
5. Breath Sounds :
6. Added Sounds :
2. Tenderness :
3. Ascites :
4. Palpable Mass :
5. Organomegaly :
6. Any Other :
Se
al
Certifying Physician
Qualifications
Reg. No.
PRE-EMPLOYMENT EVALUATION
Date: ____________
R/No.: ______________
Declaration declare that the under said information is true and correct to the best of
my knowledge.
If any of this information is found to be false / incomplete / incorrect the company can
cancel my appointment or terminate my service contract. No legal implications
PAST YOUR
RECENT
PASSPORT
SIZE
PHOTOGRAPH
Regarding the same will be borne by Bureau Veritas (India) Pvt Ltd or
Bureau Veritas Certification (India) Pvt Ltd.
SafetyofPledge
Thumb Impression
Signature
the candidate
Amelio Personnel
From this day onwards, I solemnly affirm that I will rededicate myself to the cause of safety, health
and protection of environment and will do my best to observe rules, regulations and procedure
and develop attitudes and habits conducive for achieving these objectives.
I fully realize that accidents and diseases are a drain on my Organization and the National
economy and may lead to disablement, death, damage to health and property, social suffering
and general degradation of environment.
I will do everything possible for the prevention of accidents and occupational diseases and
protection of environment in the interest of self, my family, my organization, my workplace, my
community and the nation at large.
_________________________
Left Hand Thumb Impression
_____________
Place
_____________________
Candidates Signature
______________
Date
__________________________________
Certifying Occupational Health Physician
CERTIFICATE OF FITNESS
: ____________________________________________________
3. Name
: ____________________________________________________
4. Sex
: ____________________________________________________
5. Residence
: ____________________________________________________
6. Date of Birth
: ____________________________________________________
7. Physical Fitness
: Height: ____________
Weight: _______________
Chest
: Normal: ____________
Expanded: ____________
Eyesight
: Left : _____________
Right: ________________
8. General Examination
: ____________________________________________________
__________________________
_______________
_____________________
Date