TRM 2
(Note A to Item XI of Annexure I to Chapter 8)

Form of certificate to be issued by a medical practitioner
nominated by Indian mission etc. abroad

MEDICAL CERTIFICATE

I hereby certify that I have recently personally examined____________________________________________
                                                                                           (Name - Block Letters)

_____________________________________________________________________________________________

_____________________________________________________________________________________________
                                                                (address)

and he/she is suffering from____________________________________________________________________

_____________________________________________________________________________________________
                                                                (ailment).

I recommend that he/she undergoes immediate medical treatment for which he/she will be required to stay for about_______________days in_________________________________________________________

                                                                (Name of the country)

The cost of the medical treatment will be approximately ___________________________________

Place:.................. Date:...................	_________________________________ (Signature of Medical practitioner)

Name_________________________________
Designation____________________________
Registration No.________________________
Address_______________________________
_____________________________________
_____________________________________