Form A and B (medical certificate) for claiming HPL on commutation
Form-A
MEDICAL CERTIFICATE
Signature of Applicant …………………
I,
Dr. ...................... ....................... ..……............... (name) after
careful personal examination of the case hereby certify that Sri/Smt./Ms.
………………… ………… ………….. …...…..…...…………… …………………… ………..…... (name & designation of applicant) of the
Office of the ………………………… ……………… …………………… whose signature is given above is
suffering from …………… …………………… ……………… ………………… and, therefore, I consider, that a
period of absence from duty with effect from ……………………… to ……………………... is
absolutely necessary for the restoration of his/her health.
Date:
………………
Signature of Government Medical Officer / Civil Asst Surgeon /Surgeon along with official seal
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FORM-B
FITNESS CERTIFICATE
Signature of Applicant .........................
I,
Dr. ............................. .................. ……...............(name) after
careful personal examination of the case hereby certify that Sri /Smt./Ms.
…………… ………… ………… ……..…...…..… ...…………… ………………… …………..…... (name & designation of applicant) of the
Office of the …………… ……………… …… ……… ………… ………… whose signature is given above, and found
that he/she has recovered from his/her illness and is now fit to resume duties
in Government service from ………… …………..(date) I also certify that before arriving at
this decision, I have examined the original medical certificate and statement
of the case (or certified copies thereof) on which leave was granted or
extended and have taken these into consideration in arriving at my decision.
Place:
………………
Date:
………………
Signature of Government Medical Officer / Civil
Asst Surgeon /Surgeon along with official seal
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