Medical Report Form (For Arms Licence) 1. Name of Person who was examined 2. Address of the person examined 3. Marks of Identification 4. What is the apparement age? 5. If the applicant to the best of your judgement subject to any disease or mental ailment efficiency, 6. Does the applicant suffer from any heart or lungs Disorder, which might interfere with the performance Of his duties as Arms Licenser. 7. Is there defect in size. If so, it has been correct by Suitable spectacles. 8. Does the applicant suffer from a degree or deafness Which would present his hearing the ordinary sound Signal? 9. Was the applicant any deformity or loss of member Which would interfere with performance of his as Arms Licence. 10. Is he in your condition generally fit as records body health. I certify that to the best of my knowledge and belief the applicant ............ is the person, herein above described that the attached photographs is a responsible correct likeliness. Signature Certifying Medical Officer Designation Dated: PHOTO
