"Candidate Self Declaration"

Date :
Affix your photograph
Date of Birth: _______________________________

Name :
Father's/ Spouse Name
Current Address

Position Applied For (Optional)

Date of Joining (Optional)
Blood Group (Mandatory) Contact number

PERSONAL HISTORY (Tick whichever applicable)

1) Height(in cms) ------------------ Weight in Kg:-----------

2) Do you smoke ? (Yes / No)

3) Do you take Alcohol ? (Yes / No)
4) Do you take tobacco ? (Yes / No)

5) Do you wear spectacles ? (Yes / No) If Yes, Power of Glass Left:---------

Right :---------
6) Do you use "Contact Lens"? (Yes / No)
7) Are you colour blind ? (Yes / No)

8) Are you suffering from High BP? (Yes / No) Since how many years ? -------- Medicines taken:-----------------------------------------
9) Are you suffering from Diabetes ? (Yes / No) Since how many years ?-------- Medicines taken :-----------------------------------------

10) Are you suffering from major heart disease ? (Yes / No) If yes, details --------------------------------------------------------------

11) Are you suffering from Anaemia ? (Yes / No)

12) Are you having any ear diseases ? (Yes / No)

13) Are you suffering from Asthama ? (Yes / No)

14) Are you suffering from kidney disease ? (Yes / No)
15) Have you undergone any surgery ? (Yes / No) If yes, please let us know the details----------------------------------------

16) Are you suffering from TB ? (Yes / No)

17) Do you have any bleeding disoder ? (Yes / No)

18) Are you suffering fromany skin diseases ? (Yes / No)

(a) Psoriasis: (Yes / No)
(b) External Eczema: (Yes / No)
(c) External Acne : (Yes / No)

19) Are you taking any treatment from Psychiatrist ? (Yes / No) If yes, details --------------------------------------------------------------

20) Are you having swelling in groin (hydrocoel/hernea/varicocoel) ? (Yes / No)--for male candidates only

For Female candidates only

1. Are your periods regular?( Yes / No)
2. Date of last periods _____________
3. Have you taken any long-term medical treatment for gynec problem? If yes please specify/ NO
________________________________________________________________________________________________

Certified that the particulars given by me in the foregoing above are true, complete and to the best of my knowledge & belief.
If any of this information is found to be false/ incomplete / incorrect, the company can cancel my appointment letter or terminate
my employment service contract / employment.

I have / have not undergone pre-employment medical check up for TATA TECHNOLOGIES in the past.

Signature of the candidate

____________________________
Version 1.1_13012014_confidential Name of the candidate