Back

SECTION C – CANDIDATE DECLARATION

I certify that the information provided in this assessment and to the examining doctor is to the best of my knowledge and belief correct.

NOTE: Statements found to be false within the knowledge of the applicant will make he/she, if appointed, liable to dismissal.

I hereby authorise the doctor to communicate with my own doctor/s concerning any of the conditions contained within this assessment and also give my consent for the transfer of all related personal medical information and/or history to my prospective employer.

Signature:
Witness: (Medical Examiner)
Name:
Name:
Dated this day of 20
Photographic ID:
Sighted by:

The purpose of this pre-employment medical is to medically assess the candidate only for the position that is requested. It should not be used to assess the suitability for another position or other employment.

40876177572D0814DA333CCC88C127E5