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<?php
error_reporting(E_ERROR | E_PARSE);
?>
<link href="<?php echo base_url().'assets/css/formstyle.css'?>" rel="stylesheet" type="text/css"/>
<DIV id="page_3">
<TABLE cellpadding=0 cellspacing=0 class="t4">
<TR>
<TD class="tr22 td267"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td268"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td269"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td17"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td237"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td56"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td270"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td271"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td4"><P class="p7 ft74"> </P></TD>
<TD colspan=4 class="tr22 td53"><P class="p24 ft75">Appendix– V</P></TD>
</TR>
<TR>
<TD class="tr22 td272"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td273"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td274"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td275"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td243"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td276"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td277"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td278"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td279"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td280"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td281"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td282"><P class="p7 ft74"> </P></TD>
<TD class="tr22 td283"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr25 td267"><P class="p7 ft74"> </P></TD>
<TD class="tr25 td268"><P class="p7 ft74"> </P></TD>
<TD class="tr25 td269"><P class="p7 ft74"> </P></TD>
<TD class="tr25 td17"><P class="p7 ft74"> </P></TD>
<TD colspan=4 class="tr25 td284"><P class="p43 ft76">SIGHT TEST CERTIFICATE</P></TD>
<TD class="tr25 td4"><P class="p7 ft74"> </P></TD>
<TD class="tr25 td8"><P class="p7 ft74"> </P></TD>
<TD class="tr25 td285"><P class="p7 ft74"> </P></TD>
<TD class="tr25 td37"><P class="p7 ft74"> </P></TD>
<TD class="tr25 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr10 td267"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td268"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td269"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td17"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td237"><P class="p7 ft74"> </P></TD>
<TD colspan=2 class="tr10 td51"><P class="p72 ft77">New Entry*/Periodic*</P></TD>
<TD class="tr10 td271"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td4"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td8"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td285"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td37"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr10 td272"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td273"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td274"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td275"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td243"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td276"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td277"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td278"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td279"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td280"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td281"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td282"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td283"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD colspan=3 class="tr6 td286"><P class="p23 ft78">Reference No.</P></TD>
<TD class="tr6 td287"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td237"><P class="p13 ft78"><?=$customer['lead_id']?></P></TD>
<TD class="tr6 td56"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td270"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td288"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td4"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td8"><P class="p7 ft74"> </P></TD>
<TD colspan=3 class="tr6 td289"><P class="p8 ft79">Form B :</P></TD>
</TR>
<TR>
<TD class="tr16 td272"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td273"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td290"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td243"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td276"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td277"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td291"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td279"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td280"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td281"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td282"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td283"><P class="p7 ft80"> </P></TD>
</TR>
<TR>
<TD colspan=3 class="tr6 td286"><P class="p23 ft78">Full Name</P></TD>
<TD class="tr6 td287"><P class="p7 ft74"> </P></TD>
<TD colspan=2 class="tr6 td292"><P class="p13 ft78"><?=$customer['customer_name']?></P></TD>
<TD class="tr6 td270"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td288"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td4"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td8"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td285"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td37"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr2 td267"><P class="p7 ft81"> </P></TD>
<TD class="tr2 td268"><P class="p7 ft81"> </P></TD>
<TD class="tr2 td269"><P class="p7 ft81"> </P></TD>
<TD class="tr2 td287"><P class="p7 ft81"> </P></TD>
<TD class="tr2 td237"><P class="p7 ft81"> </P></TD>
<TD class="tr2 td56"><P class="p7 ft81"> </P></TD>
<TD class="tr2 td270"><P class="p7 ft81"> </P></TD>
<TD class="tr2 td288"><P class="p7 ft81"> </P></TD>
<TD class="tr2 td4"><P class="p7 ft81"> </P></TD>
<TD class="tr2 td8"><P class="p7 ft81"> </P></TD>
<TD class="tr14 td281"><P class="p7 ft82"> </P></TD>
<TD class="tr14 td282"><P class="p7 ft82"> </P></TD>
<TD class="tr2 td6"><P class="p7 ft81"> </P></TD>
</TR>
<TR>
<TD class="tr20 td272"><P class="p7 ft83"> </P></TD>
<TD class="tr20 td273"><P class="p7 ft83"> </P></TD>
<TD class="tr20 td274"><P class="p7 ft83"> </P></TD>
<TD class="tr20 td290"><P class="p7 ft83"> </P></TD>
<TD class="tr20 td243"><P class="p7 ft83"> </P></TD>
<TD class="tr20 td276"><P class="p7 ft83"> </P></TD>
<TD class="tr20 td277"><P class="p7 ft83"> </P></TD>
<TD class="tr20 td291"><P class="p7 ft83"> </P></TD>
<TD class="tr23 td4"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td293"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td285"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td294"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td6"><P class="p7 ft84"> </P></TD>
</TR>
<TR>
<TD colspan=3 class="tr6 td286"><P class="p23 ft78">Rank</P></TD>
<TD class="tr6 td287"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td292"><P class="p13 ft78"><?=$customer['rank']?></P></TD>
<TD class="tr6 td56"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td270"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td288"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td4"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td293"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td285"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td294"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr16 td272"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td273"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td290"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td243"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td276"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td277"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td291"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td4"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td293"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td285"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td294"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
<TR>
<TD colspan=3 class="tr6 td286"><P class="p23 ft78">PP/CDC/ ID No.</P></TD>
<TD class="tr6 td287"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td237"><P class="p13 ft78"><?=$customer['passport_no']?></P></TD>
<TD class="tr6 td56"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td270"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td288"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td4"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td293"><P class="p7 ft74"> </P></TD>
<TD colspan=2 rowspan=2 class="tr21 td295"><P class="p31 ft86">Photograph</P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr16 td272"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td273"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td290"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td243"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td276"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td277"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td291"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td4"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td293"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
<TR>
<TD colspan=3 class="tr6 td286"><P class="p23 ft87">Date & Place of Birth</P></TD>
<TD class="tr6 td287"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td237"><P class="p13 ft78"><NOBR><?php echo date("d-m-Y", strtotime($customer['dob']));?></NOBR></P></TD>
<TD class="tr6 td56"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td270"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td288"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td4"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td293"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td285"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td294"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr16 td272"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td273"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td290"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td243"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td276"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td277"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td291"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td4"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td293"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td285"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td294"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
<TR>
<TD colspan=3 class="tr6 td286"><P class="p23 ft78">Colour of Eyes</P></TD>
<TD class="tr6 td287"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td237"><P class="p13 ft78">BLACK</P></TD>
<TD class="tr6 td56"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td270"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td288"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td4"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td293"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td285"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td294"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr16 td272"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td273"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td290"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td243"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td276"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td277"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td291"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td4"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td293"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td285"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td294"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
<TR>
<TD colspan=3 class="tr19 td286"><P class="p23 ft88">Identification Notes</P></TD>
<TD class="tr19 td287"><P class="p7 ft74"> </P></TD>
<TD class="tr19 td237"><P class="p13 ft78"><?=$customer['identification_notes']?></P></TD>
<TD class="tr19 td56"><P class="p7 ft74"> </P></TD>
<TD class="tr19 td270"><P class="p7 ft74"> </P></TD>
<TD class="tr19 td288"><P class="p7 ft74"> </P></TD>
<TD class="tr19 td4"><P class="p7 ft74"> </P></TD>
<TD class="tr19 td293"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td281"><P class="p7 ft74"> </P></TD>
<TD class="tr10 td296"><P class="p7 ft74"> </P></TD>
<TD class="tr19 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr23 td272"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td273"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td274"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td290"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td243"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td276"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td277"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td291"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td279"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td280"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td281"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td282"><P class="p7 ft84"> </P></TD>
<TD class="tr23 td283"><P class="p7 ft84"> </P></TD>
</TR>
<TR>
<TD class="tr11 td267"><P class="p7 ft89"> </P></TD>
<TD class="tr13 td273"><P class="p7 ft90"> </P></TD>
<TD class="tr13 td274"><P class="p7 ft90"> </P></TD>
<TD class="tr13 td275"><P class="p7 ft90"> </P></TD>
<TD class="tr13 td243"><P class="p7 ft90"> </P></TD>
<TD class="tr13 td276"><P class="p7 ft90"> </P></TD>
<TD class="tr13 td277"><P class="p7 ft90"> </P></TD>
<TD class="tr13 td278"><P class="p7 ft90"> </P></TD>
<TD class="tr13 td279"><P class="p7 ft90"> </P></TD>
<TD class="tr13 td280"><P class="p7 ft90"> </P></TD>
<TD class="tr13 td281"><P class="p7 ft90"> </P></TD>
<TD class="tr11 td37"><P class="p7 ft89"> </P></TD>
<TD class="tr11 td6"><P class="p7 ft89"> </P></TD>
</TR>
<TR>
<TD class="tr6 td297"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td268"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td269"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td17"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td298"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td299"><P class="p34 ft91">Right Eye</P></TD>
<TD class="tr6 td300"><P class="p73 ft91">Left Eye</P></TD>
<TD class="tr6 td271"><P class="p74 ft91">Both Eyes</P></TD>
<TD class="tr6 td301"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td8"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td302"><P class="p14 ft79">Result</P></TD>
<TD class="tr6 td37"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr15 td297"><P class="p7 ft85"> </P></TD>
<TD class="tr16 td273"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td275"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td303"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td304"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td305"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td278"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td306"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td280"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td307"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td37"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
<TR>
<TD class="tr6 td297"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td308"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td269"><P class="p7 ft74"> </P></TD>
<TD colspan=2 class="tr6 td309"><P class="p7 ft78">Unaided</P></TD>
<TD class="tr6 td299"><P class="p73 ft78"><?=$customer['dreuc']?></P></TD>
<TD class="tr6 td300"><P class="p73 ft78"><?=$customer['dleuc']?></P></TD>
<TD class="tr6 td271"><P class="p74 ft78">6/6</P></TD>
<TD class="tr6 td301"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td8"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td302"><P class="p8 ft78">Normal</P></TD>
<TD class="tr6 td37"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr15 td297"><P class="p7 ft85"> </P></TD>
<TD rowspan=2 class="tr21 td308"><P class="p73 ft77">Distance Vision</P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td275"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td303"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td304"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td305"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td278"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td306"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td280"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td307"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td37"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
<TR>
<TD class="tr6 td297"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td269"><P class="p7 ft74"> </P></TD>
<TD colspan=2 class="tr6 td309"><P class="p7 ft78">Aided</P></TD>
<TD class="tr6 td299"><P class="p73 ft78"><?=$customer['drec']?></P></TD>
<TD class="tr6 td300"><P class="p73 ft78"><?=$customer['dlec']?></P></TD>
<TD class="tr6 td271"><P class="p74 ft78">6/6</P></TD>
<TD class="tr6 td301"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td8"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td302"><P class="p8 ft78">Normal</P></TD>
<TD class="tr6 td37"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr15 td297"><P class="p7 ft85"> </P></TD>
<TD class="tr16 td310"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td275"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td303"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td304"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td305"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td278"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td306"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td280"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td307"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td37"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
<TR>
<TD class="tr6 td297"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td308"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td269"><P class="p7 ft74"> </P></TD>
<TD colspan=2 class="tr6 td309"><P class="p7 ft78">Unaided</P></TD>
<TD class="tr6 td299"><P class="p34 ft78">N/5</P></TD>
<TD class="tr6 td300"><P class="p75 ft78">N/5</P></TD>
<TD class="tr6 td271"><P class="p74 ft78">N/5</P></TD>
<TD class="tr6 td301"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td8"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td302"><P class="p8 ft78">Normal</P></TD>
<TD class="tr6 td37"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr15 td297"><P class="p7 ft85"> </P></TD>
<TD rowspan=2 class="tr21 td308"><P class="p73 ft77">Near Vision</P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td275"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td303"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td304"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td305"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td278"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td306"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td280"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td307"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td37"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
<TR>
<TD class="tr6 td297"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td269"><P class="p7 ft74"> </P></TD>
<TD colspan=2 class="tr6 td309"><P class="p7 ft78">Aided</P></TD>
<TD class="tr6 td299"><P class="p34 ft78">N/5</P></TD>
<TD class="tr6 td300"><P class="p75 ft78">N/5</P></TD>
<TD class="tr6 td271"><P class="p74 ft78">N/5</P></TD>
<TD class="tr6 td301"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td8"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td302"><P class="p8 ft78">Normal</P></TD>
<TD class="tr6 td37"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr15 td297"><P class="p7 ft85"> </P></TD>
<TD class="tr16 td310"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td275"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td303"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td304"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td305"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td278"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td306"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td280"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td307"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td37"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
<TR>
<TD class="tr6 td297"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td308"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td269"><P class="p7 ft74"> </P></TD>
<TD colspan=2 class="tr6 td309"><P class="p7 ft78">Horizontal Plan</P></TD>
<TD class="tr6 td299"><P class="p34 ft78">Normal</P></TD>
<TD class="tr6 td300"><P class="p73 ft78">Normal</P></TD>
<TD class="tr6 td271"><P class="p74 ft78">Normal</P></TD>
<TD class="tr6 td301"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td8"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td302"><P class="p8 ft78">Normal</P></TD>
<TD class="tr6 td37"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr15 td297"><P class="p7 ft85"> </P></TD>
<TD rowspan=2 class="tr21 td308"><P class="p73 ft77">Field of Vision</P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td275"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td303"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td304"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td305"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td278"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td306"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td280"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td307"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td37"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
<TR>
<TD class="tr6 td297"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td269"><P class="p7 ft74"> </P></TD>
<TD colspan=2 class="tr6 td309"><P class="p7 ft78">Vertical Plan</P></TD>
<TD class="tr6 td299"><P class="p34 ft78">Normal</P></TD>
<TD class="tr6 td300"><P class="p73 ft78">Normal</P></TD>
<TD class="tr6 td271"><P class="p74 ft78">Normal</P></TD>
<TD class="tr6 td301"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td8"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td302"><P class="p8 ft78">Normal</P></TD>
<TD class="tr6 td37"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr15 td297"><P class="p7 ft85"> </P></TD>
<TD class="tr16 td310"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td275"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td303"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td304"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td305"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td278"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td306"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td280"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td307"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td37"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
<TR>
<TD class="tr6 td297"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td308"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td269"><P class="p7 ft74"> </P></TD>
<TD colspan=2 class="tr6 td309"><P class="p7 ft78">Ishihara</P></TD>
<TD class="tr6 td56"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td270"><P class="p76 ft78">Normal</P></TD>
<TD class="tr6 td271"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td301"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td8"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td302"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td37"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr15 td297"><P class="p7 ft85"> </P></TD>
<TD rowspan=2 class="tr21 td308"><P class="p73 ft77">Colour Vision</P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td275"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td303"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td276"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td277"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td278"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td306"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td280"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td307"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td37"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
<TR>
<TD class="tr6 td297"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td269"><P class="p7 ft74"> </P></TD>
<TD colspan=2 class="tr6 td309"><P class="p7 ft78">Lantern / Others</P></TD>
<TD class="tr6 td56"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td270"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td271"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td301"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td8"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td302"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td37"><P class="p7 ft74"> </P></TD>
<TD class="tr6 td6"><P class="p7 ft74"> </P></TD>
</TR>
<TR>
<TD class="tr15 td297"><P class="p7 ft85"> </P></TD>
<TD class="tr16 td310"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td274"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td275"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td303"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td276"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td277"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td278"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td306"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td280"><P class="p7 ft80"> </P></TD>
<TD class="tr16 td307"><P class="p7 ft80"> </P></TD>
<TD class="tr15 td37"><P class="p7 ft85"> </P></TD>
<TD class="tr15 td6"><P class="p7 ft85"> </P></TD>
</TR>
</TABLE>
<P class="p77 ft93">I, <SPAN class="ft92">Dr. Ushas Kumar G</SPAN> hereby certify that the above mentioned candidate has met/not met*, the eye sight standard for his/her designated rank / position as set out in <NOBR>Annex-II* /Annex-</NOBR> III* for seafaring occupation.</P>
<TABLE cellpadding=0 cellspacing=0 class="t5">
<TR>
<TD class="tr1 td311"><P class="p7 ft88">Candidate’s Signature</P></TD>
<TD class="tr1 td312"><P class="p78 ft88">Signature of the Medical Examiner</P></TD>
</TR>
<TR>
<TD class="tr24 td311"><P class="p7 ft88">Date:<?php echo date("d-m-Y", strtotime($customer['added_date']));?></P></TD>
<TD class="tr24 td312"><P class="p7 ft88">at : Kochi</P></TD>
</TR>
</TABLE>
<P class="p79 ft95"><SPAN class="ft94">Note</SPAN>:</P>
<P class="p80 ft98"><SPAN class="ft88">1)</SPAN><SPAN class="ft96">This certificate is valid for </SPAN><SPAN class="ft97">two years</SPAN> from the above date. New entry sight test certificates should be retained by the candidate till his active sea career.</P>
<P class="p81 ft93"><SPAN class="ft88">2)</SPAN><SPAN class="ft99">Seafarer aggrieved by the decision of the Medical Examiner may appeal as per the provision of the M.S. (Medical Examination) Rules, 2000 as amended.</SPAN></P>
<P class="p82 ft88"><SPAN class="ft88">*</SPAN><SPAN class="ft100">Delete if not applicable.</SPAN></P>
</DIV>
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