‫‪Fit to work and travel Certificate‬‬

‫ﮔ و اھ ﯽ ﺳ ﻼ ﻣ ت ﺑر ای ﮐ ﺎر و ﺳ ﻔ ر‬
‫د ﮐ ﺎ ر ا و ﺳ ﻔ ر ﻟ ﭘ ﺎر ه د ر و ﻏ ﺗ ﯾ ﺎ ﺳ ﻧد‬

‫‪The medical report below is to be completed by a registered nurse or medical practitioner.‬‬

‫‪.‬راﭘﻮر ﺻﺤﯽ ذﯾﻞ ﺑﺎﯾﺪ ﺗﻮﺳﻂ ﯾﮏ ﭘﺮﺳﺘﺎر ﺛﺒﺖ ﺷﺪه ﯾﺎ ﯾﮏ داﮐﺘﺮ ﺧﺎﻧﮫ ﭘﺮی ﺷﻮد‬
‫ﻻ ﻧ د ې ط ﺑ ﻲ ر ا ﭘ و ر ﺑ ﺎ ﯾ د د ر ا ﺟ ﺳ ﺗ ر ﺷ و ي ﻧ ر س ﯾ ﺎ ط ﺑ ﻲ ﻣ ﺗ ﺧ ﺻص ﻟ ﺧ و ا ﺑ ﺷ ﭘ ړ ﺷ ﻲ ‪.‬‬

‫ا ﺳ م ﮐ ﺎ ر ﻣ ﻧ د ‪ /‬د ﮐ ﺎ ر ﮐ و ﻧ ﮑ ﻲ ﻧ و م ‪Employee/Consultant Name /‬‬

‫………………………………………… ‪I, …………………………………………………………….. of Medical Practice,‬‬

‫‪on this ……… day of ……………………. 20 ……….. hereby declare that this medical report is true and correct. I‬‬
‫‪understand that the working environment where potential employee/consultant will be, is considered difficult and‬‬
‫‪that there is potential travel involved.‬‬
‫‪I hereby confirm this potential employee/consultant of CTG Global is FIT / NOT FIT to work in:‬‬
‫……………………………………………………………………………………………………………………………………‬

‫‪Signature of medical professional:‬‬ ‫‪…………………………..…………………………………………………….…..‬‬

‫‪Stamp:‬‬ ‫‪….…….....……...……………………………………..…………………...……………………...……………….‬‬

‫‪Date:‬‬ ‫‪……………..……….…………………………………………………………………………………………………..‬‬

‫ﻣﻦ‪ .......................‬از ﻣﺮﮐﺰ ﺗﺪاوی ‪ ...................‬ﺑﮫ روز ‪.....................‬ﺗﺎرﯾﺦ‪............................‬ﺳﺎل ‪...................‬ﺑﺪﯾﻨﻮﺳﯿﻠﮫ‬

‫اﻋﻼم ﻣﯽﮐﻨﻢ ﮐﮫ اﯾﻦ ﮔﺰارش ﺻﺤﯽ ﺻﺤﯿﺢ و درﺳﺖ اﺳﺖ‪ .‬ﻣﻦ درک ﻣﯽﮐﻨﻢ ﮐﮫ ﻣﺤﯿﻂ ﮐﺎری ﮐﮫ ﮐﺎرﻣﻨﺪ اﺣﺘﻤﺎﻟﯽ در آن ﺧﻮاھﺪ ﺑﻮد‪،‬‬
‫دﺷﻮار در ﻧﻈﺮ ﮔﺮﻓﺘﮫ ﻣﯽﺷﻮد و اﺣﺘﻤﺎل ﺳﻔﺮ ﻧﯿﺰ وﺟﻮد دارد‪ .‬ﺑﺪﯾﻨﻮﺳﯿﻠﮫ ﺗﺄﯾﯿﺪ ﻣﯽﮐﻨﻢ ﮐﮫ اﯾﻦ ﮐﺎرﻣﻨﺪ اﺣﺘﻤﺎﻟﯽ از ‪ CTG Global‬ﺑﺮای ﮐﺎر‬
‫در اﯾﻨﺠﺎ ﻣﻨﺎﺳﺐ ‪ /‬ﻧﺎﻣﻨﺎﺳﺐ اﺳﺖ‪:‬‬

‫زه‪ ...................................‬د ‪ ................................‬درﻣﻠﻨﯥ ﻣﺮﮐﺰ^ﺨﮫ ﭘﮫ ‪ .............................‬ورځ‪،‬ﭘﮫ ‪..........................‬‬

‫ﻧﯿ‪b‬ﮫ‪ ،‬ﭘﮫ‪....................‬ﮐﺎل‪ ،‬ﭘﮫ دې ﺗﻮ‪d‬ﮫ اظﮭﺎر ﻟﺮم ﭼﯥ دا روﻏﺘﯿﺎﯾﯽ راﭘﻮر رﯾ‪i‬ﺘﯿﻨﯽ او ﺳﻢ دی‪ .‬زه ﭘﻮھﯿ‪j‬م ﭼﯥ د ﮐﺎر ﭼﺎﭘﯿﺮﯾﺎل ﭼﯥ‬
‫اﺣﺘﻤﺎﻟﻲ ﮐﺎرﻣﻨﺪ ﺑﮫ ﭘﮫ ﮐﯥ وي ﺳﺘﻮﻧﺰﻣﻦ ‪md‬ﻞ ﮐﯿ‪j‬ي او د ﺳﻔﺮ اﺣﺘﻤﺎل ﻟﺮي‪ .‬زه ﭘﮫ دې ﺗﻮ‪d‬ﮫ ﺗﺼﺪﯾﻖ ﮐﻮم ﭼﯥ د ‪^ CTG Global‬ﺨﮫ دا‬
‫اﺣﺘﻤﺎﻟﻲ ﮐﺎرﻣﻨﺪ دﻟﺘﮫ د ﮐﺎر ﮐﻮﻟﻮ ﻟﭙﺎره ﻣﻨﺎﺳﺐ ‪ /‬ﻧﺎ ﻣﻨﺎﺳﺐ دی‪:‬‬
‫اﻣﺿﺎء داﮐﺗر ‪ /‬د ډاﮐﺗر اﻣﺿﺎء‪……………………………………………………………………………………. :‬‬
‫ﻣﮭر‪5 /‬ﺎﭘﮫ‪……………………….…………………………………………………………………………… :‬‬
‫ﺗﺎرﯾﺦ ‪ /‬ﻧﯧ*ﮫ‪..………………………………………………………………………….……………………… :‬‬

‫‪www.ctg.org‬‬ ‫‪Darya Village Hawa Shinasi Road PD9, Kabul, Afghanistan, www.ctgglobal.com‬‬ ‫‪1‬‬
‫ﻣ ﻌ ﻠ ﻮ ﻣ ﺎ ت ﺷ ﺨ ﺼ ﯽ ‪ /‬د ﮐ ﺎ ر ﮐ ﻮ ﻧ ﮑ ﻲ ﺷ ﺨ ﺼ ﻲ ﻣ ﻌ ﻠ ﻮ ﻣ ﺎ ت ‪Personal Details /‬‬

‫ﻧوم‪Employee / Consultant Name / :‬‬ ‫اﺳم ﮐﺎرﻣﻧد ‪ /‬د ﮐﺎرﮐوﻧﮑﻲ‬

‫‪Nationality /‬‬ ‫‪:‬ﻣﻠﯾت ‪/‬ﻣﻠﯾت‬
‫‪.‬‬

‫ﻋﻤﺮ ‪Age‬‬ ‫‪:‬ﺳﻦ ‪/‬‬

‫‪Sex‬‬ ‫‪:‬ﺟﻧﺳﯾت ‪/‬ﺟﻧﺳﯾت ‪/‬‬

‫‪Passport Number‬‬ ‫ﻧﻣﺑر ﭘﺎﺳﭘورت ‪ /‬د ﭘﺎﺳﭘورټ ﺷﻣﭔره‪/‬‬ ‫‪:‬‬

‫‪Place of issue‬‬ ‫‪:‬ﻣﺣل ﺻدور‪ /‬د ﺻدور ‪H‬ﺎی ‪/‬‬

‫‪Date of issue‬‬ ‫‪:‬ﺗﺎرﯾﺦ ﺻدور ‪/‬د ﺻدور ﻧﭔ‪L‬ﮫ ‪/‬‬

‫‪Country Applied for /‬‬ ‫ﮐﺸﻮری ﮐﮫ ﺑﮫ آن درﺧﻮاﺳﺖ داده ‪ /‬ھﯿﻮاد ﭼﯥ ﻏﻮ;ﺘﻨﻠﮏ ورﺗﮫ ﺷﻮی‪:‬‬

‫‪Marital Status/‬‬ ‫‪ :‬ﺣﺎﻟﺖ ﻣﺪﻧﯽ‪ /‬ﻣﺪﻧﻲ ﺣﺎﻟﺖ‬

‫اﯾﺪ‪ /‬ھﻐﮫ ﭘﻮﺳ‪ ,‬ﭼﯥ ﻏﻮ‪0‬ﺘﻨﮫ ﻣﻮ ورﺗﮫ ﻟﯿ‪9‬ﻟﯥ ‪Position applied for/‬‬ ‫‪:‬ﺑﺴﺖ ﮐﮫ ﺑﮫ آن درﺧﻮاﺳﺖ داده‬

‫‪www.ctg.org‬‬ ‫‪Darya Village Hawa Shinasi Road PD9, Kabul, Afghanistan, www.ctgglobal.com‬‬ ‫‪2‬‬
‫‪/‬ﺗﺎرﯾﺨﭽﮫ ﺻﺤﯽ‪ /‬روﻏﺘﯿﺎﯾﻲ ﺗﺎرﯾﺨﭽﮫ ‪Medical History /‬‬

‫‪Applicant to declare all current and historical medical and surgical conditions.‬‬
‫‪.‬ﻣﺗﻘﺎﺿﯽ ﺑﺎﯾد ﺗﻣﺎم ﺷراﯾط ﺻﺣﯽ و ﺟراﺣﯽ ﻓﻌﻠﯽ و ﮔذﺷﺗﮫ را اﻋﻼم ﮐﻧد ‪] /‬ﺗوﻧﮑﯽ ﺑﺎﯾد _ول اوﺳﻧﻲ او ﭘﺧواﻧﻲ طﺑﻲ او ﺟراﺣﻲ ﺷراﯾط اظﮭﺎر ﮐړي‬

‫)‪Allergies (incl. Food, medication‬‬

‫آ ﻟر ژ ی ھ ﺎ ) ﺷ ﺎﻣ ل ﻏ ذ ا‪ ،‬د ار و ( ‪/‬‬

‫ا ﻟر ﺟ ﯽ ) ﺣ ﺳ ﺎ ﺳ ﯾ ت ( ‪ ) :‬د ﺧ و ړ و ‪ ،‬د ر ﻣ ﻠ و ﭘ ﮫ ‪ A‬ډ و ن (‬

‫‪Surgical conditions / Previous Surgeries (e.g.‬‬

‫)‪Appendix, gallbladder‬‬

‫‪:‬ﺷراﯾط ﺟراﺣﯽ ‪ /‬ﺟراﺣﯽھﺎی ﻗﺑﻠﯽ )ﻣﺛًﻼ آﭘﺎﻧدﯾس‪ ،‬ﮐﯾﺳﮫ ﺻﻔرا(‬

‫ﺟراﺣﻲ ﺷراﯾط ‪ /‬ﻣﺧﮑﯾﻧﻲ ﺟراﺣﻲ )د ﺑﯾﻠ‪w‬ﯥ ﭘﮫ ﺗو‪y‬ﮫ‪ ،‬آﭘﺎﻧدﯾس‪ ،‬ﮐﯾﺳﮫ‬

‫‪:‬ﺻﻔرا(‬

‫)‪Current medications (list all, with doses‬‬

‫‪: /‬داروھﺎی ﻓﻌﻠﯽ )ھﻣﮫ را ﺑﺎ دوزھﺎ ﻓﮭرﺳت ﮐﻧﯾد(‬ ‫اوﺳﻧﻲ درﻣل) ﻟﮫ‬
‫=وﻟو دوزوﻧو ﺳره ﻟﯾﺳت ﮐړی‬

‫)‪Trauma (e.g. Broken limbs‬‬

‫ﺻ د ﻣ ﮫ ‪ /‬ﺿ ر ﺑﮫ ) د ﺑ ﯾ ﻠ‪ T‬ﯥ ﭘ ﮫ ﺗ و ‪ A‬ﮫ ﻣ ﺎ ت ﺷ و ي ‪ /‬ﺿ ر ﺑﮫ ) ﻣ ﺛ ً‬

‫ﻼ ﺷ ﮑ ﺳ ﺗﮕ ﯽ اﻋ ﺿ ﺎ(‬
‫ﻏړي‬

‫‪Historical or current illness‬‬

‫ﭘﺧواﻧﯽ او اوﺳﻧ• ﻧﺎروﻏ• ‪ /‬ﺑﯾﻣﺎریھﺎی ﮔذﺷﺗﮫ ﯾﺎ ﻓﻌﻠﯽ‬

‫)‪Mental illness (e.g. Depression, anxiety, PTSD‬‬

‫ﭘﺧواﻧﯽ او اوﺳﻧ• ﻧﺎروﻏ• ‪ /‬ﺑﯾﻣﺎریھﺎی ﮔذﺷﺗﮫ ﯾﺎ ﻓﻌﻠﯽ‬

‫‪Medical conditions (e.g. asthma, diabetes, high‬‬

‫)‪blood pressure‬‬

‫ط ﺑ ﻲ ﺷ ر ا ﯾ ط ) د ﻣ ﺛ ﺎ ل ﭘ ﮫ ‪ /‬ﺷ ر ا ﯾ ط ﭘ ز ﺷ ﮑ ﯽ ) ﻣ ﺛ ﻼً آ ﺳ م ‪ ،‬د ﯾ ﺎ ﺑ ت ‪ ،‬ﻓ ﺷ ﺎ ر ﺧ و ن ﺑ ﺎ ﻻ (‬

‫ﺗو ‪A‬ﮫ‪ ،‬آﺳ م‪ ،‬ﺷ ﮑ ر‪ ،‬د و ﯾﻧﯥ ﻟوړ ﻓﺷ ﺎر‪ ،‬او داﺳ ﯥ ﻧور (‬

‫‪www.ctg.org‬‬ ‫‪Darya Village Hawa Shinasi Road PD9, Kabul, Afghanistan, www.ctgglobal.com‬‬ ‫‪3‬‬
Medical Examination

GENERAL Height (cm) Weight (kg) Body mass

index (BMI)

Heart rate Blood pressure

CARDIOVASCULAR
Heart Failure ECG (if needed)

Respiratory Rate Oxygen Saturation (O2 Sats)

RESPIRATORY
Breath Sounds Chest X-ray (if needed)

ABDOMEN Masses, scars, hernias Other

NEUROLOGICAL Limb power, co-ordination, balance

MUSCULOSKELETAL Spine, limbs, joints

ENT Tympanic membranes, pharynx

Appearance, pupils, visual acuity

EYES
Wears spectacles Visual Acuity (R) Visual acuity (L)
VA test with VA test with
Y N spectacles spectacles

Y N Y N

www.ctg.org Darya Village Hawa Shinasi Road PD9, Kabul, Afghanistan, www.ctgglobal.com 4
Innoculations

NOTE: Doctor to provide an International Certificate of Vaccination to confirm patient has been vaccinated or
revaccinated for all relevant inoculations required for the “Country Applied for” including all standard vaccinations.

Please check the box if potential employee/consultant has received the following vaccinations:

DTP (Diphtheria, Tetanus,

COVID-19 Rabies
Pertussis)

MMR (Measles, Mumps,

Hepatitis A Polio
Rubella)

Influenza Yellow Fever Meningitis

Other
Diphtheria Hepatitis B

Pertussis Pneumonia

Typhoid Tetanus

Inoculation requirements per country available at: www.fitfortravel.nhs.uk/home

www.ctg.org Darya Village Hawa Shinasi Road PD9, Kabul, Afghanistan, www.ctgglobal.com 5
Laboratory Investigations

Investigations below: only if required (as per examining clinician).

Urine dipsticks

Urine pregnancy test

Blood Full blood count (fbc):

Malaria Thick smear / thin smear (Malaria):

Other e.g. HIV, HBsAg, VDRL:

Stool (MC&S):

I …………………………………………………………………. declare that I have provided truthful and complete

information in this form. I understand that the medical data I have voluntarily provided to CTG is confidential and
will only be accessed for the processing of medical claims, and/ or if it is vital for my condition or life and I am
unable to provide it. I agree to CTG sharing any and all of my medical data only where necessary, with relevant
third parties such as its clients, assistance company, insurance provider and medical professional in charge of
my treatment.

‫ﯾﺎ در ﺻﻮرﺗﯽ ﮐﮫ ﺑﺮای وﺿﻌﯿﺖ ﯾﺎ زﻧﺪﮔﯽ ﻣﻦ ﺣﯿﺎﺗﯽ‬/‫ ﻣﺤﺮﻣﺎﻧﮫ اﺳﺖ و ﻓﻘﻂ ﺑﺮای ﭘﺮدازش ادﻋﺎھﺎی ﺻﺤﯽ و‬،‫ اراﺋﮫ ﮐﺮدهام‬CTG ‫ﺑﮫ ﺻﻮرت داوطﻠﺒﺎﻧﮫ ﺑﮫ‬
‫ ھﺮ و ھﻤﮫ دادهھﺎی ﺻﺤﯽ ﻣﻦ را ﻓﻘﻂ در ﺻﻮرت ﻟﺰوم ﺑﺎ طﺮفھﺎی ﺛﺎﻟﺚ‬CTG ‫ ﻣﻦ ﻣﻮاﻓﻘﻢ ﮐﮫ‬.‫ دﺳﺘﺮﺳﯽ ﺧﻮاھﺪ داﺷﺖ‬،‫ﺑﺎﺷﺪ و ﻣﻦ ﻗﺎدر ﺑﮫ اراﺋﮫ آن ﻧﺒﺎﺷﻢ‬
.‫ اراﺋﮫدھﻨﺪه ﺑﯿﻤﮫ و طﺒﯿﺐ ﻣﺴﺌﻮل ﺗﺪاوی ﻣﻦ ﺑﮫ اﺷﺘﺮاک ﺑﮕﺬارد‬،‫ ﺷﺮﮐﺖ ﮐﻤﮏرﺳﺎﻧﯽ‬،‫ﻣﺮﺑﻮطﮫ ﻣﺎﻧﻨﺪ ﻣﺸﺘﺮﯾﺎن‬

‫م ﭼﯥ ھﻐﮫ روﻏﺘﯿﺎﯾﯽ ﻣﻌﻠﻮﻣﺎت ﭼﯥ ﻣﺎ ﭘﮫ‬r‫ زه ﭘﻮھﯿ‬.‫ي دي‬o‫ ﻣﻌﻠﻮﻣﺎت وړاﻧﺪې ﮐ‬o‫زه ……………… اظﮭﺎر ﮐﻮم ﭼﯥ ﻣﺎ ﭘﮫ دې ﻓﻮرﻣﮫ ﮐﯥ ﺳﻢ او ﺑﺸﭙ‬
‫ﯾﺎ ﮐﮫ دا زﻣﺎ ﺣﺎﻟﺖ ﯾﺎ ژوﻧﺪ‬/‫ﺎﻧﻮ ﭘﺮوﺳﺲ ﮐﻮﻟﻮ ﻟﭙﺎره ﺑﮫ ﻻﺳﺮﺳﯽ وﻣﻮﻣﻲ او‬u‫ي دي ﻣﺤﺮم دي او ﯾﻮازې د روﻏﺘﯿﺎ ادﻋﺎ‬o‫ ﺗﮫ ﭼﻤﺘﻮ ﮐ‬CTG ‫ﮫ‬u‫داوطﻠﺒﺎﻧﮫ ﺗﻮ‬
‫ي ﻟﮑﮫ‬o‫ ﺑﮫ زﻣﺎ ھﺮ ﯾﻮ او {ﻮل روﻏﺘﯿﺎﯾﯽ ﻣﻌﻠﻮﻣﺎت د اړوﻧﺪه درﯾﻤﯥ ډﻟﯥ ﺳﺮه ﺷﺮﯾﮏ ﮐ‬CTG ‫ زه ﻣﻮاﻓﻖ ﯾﻢ ﭼﯥ‬.‫م‬o‫ﻟﭙﺎره ﻣﮭﻢ وي او زه ﻧﺸﻢ ﮐﻮﻟﯽ ﭼﻤﺘﻮ ﮐ‬
.‫ د ﺑﯿﻤﯥ ﭼﻤﺘﻮ ﮐﻮﻧﮑﻲ او زﻣﺎ د درﻣﻠﻨﯥ ډاﮐ~ﺮ ﺳﺮه ﯾﻮازې د اړﺗﯿﺎ ﭘﮫ ﺻﻮرت ﮐﯥ‬،‫ ﻣﺮﺳﺘﻨﺪوﯾﮫ ﺷﺮﮐﺘﻮﻧﮫ‬،‫ﭘﯿﺮودوﻧﮑﻲ‬

I consent// ‫زه رﺿﺎﯾﺖ ﻟﺮم ﻣﻦ رﺿﺎﯾﺖ دارم‬ I do not consent / ‫ زه رﺿﺎﯾﺖ ﻧﻠﺮم‬/ ‫ﻣﻦ رﺿﺎﯾﺖ ﻧﺪارم‬

www.ctg.org Darya Village Hawa Shinasi Road PD9, Kabul, Afghanistan, www.ctgglobal.com 6
I understand that I am obliged to inform CTG if I contract any contagious diseases while under the CTG Consultancy
Agreement and that CTG may disclose this information to relevant parties in order to protect other Stakeholders.
If I am appointed and it is subsequently found that I failed to disclose important medical information, I understand
that CTG may take action which may lead to recovering any incurred costs and terminating the agreement.

‫ ﻣﻤﮑﻦ‬CTG ‫ ﻣﻄﻠﻊ ﮐﻨﻢ و‬CTG ‫ را در ﺻﻮرت اﺑﺘﻼ ﺑﮫ ھﺮﮔﻮﻧﮫ ﺑﯿﻤﺎری ﻣﺴﺮی در طﻮل ﻣﺪت ﻗﺮارداد ﻣﺸﺎوره ﺑﺎ‬CTG ‫ﻣﻦ درک ﻣﯽﮐﻨﻢ ﮐﮫ ﻣﻮظﻒ ھﺴﺘﻢ‬
.‫اﺳﺖ اﯾﻦ اطﻼﻋﺎت را ﺑﮫ طﺮفھﺎی ﻣﺮﺑﻮطﮫ ﺑﺮای ﺣﻔﺎظﺖ از ﺳﺎﯾﺮ ذﯾﻨﻔﻌﺎن اﻓﺸﺎ ﮐﻨﺪ‬

‫ او دا ﭼﯥ‬، ‫م‬o‫ ﺗﮫ ﺧﺒﺮ ورﮐ‬CTG ‫ون ﭘﮫ ﻣﻮده ﮐﯥ ﭘﮫ ﮐﻮﻣﮫ ﺳﺎري ﻧﺎروﻏ„ اﺧﺘﮫ ﺷﻢ‬o‫ ﺳﺮه زﻣﺎ د ﮐﺎرﻣﻨﺪی ﺗ‬CTG ‫م او ﻣﮑﻠﻒ ﯾﻢ ﭼﯥ ﮐﮫ ﭼﯿﺮې د‬r‫زه ﭘﻮھﯿ‬
.‫ي‬o‫ ﮐﻮﻟﯽ ﺷﻲ دا ﻣﻌﻠﻮﻣﺎت اړوﻧﺪو اړﺧﻮﻧﻮ ﺗﮫ د ﻧﻮرو ﺷﺮﯾﮑﺎﻧﻮ د ﺳﺎﺗﻨﯥ ﻟﭙﺎره اﻓﺸﺎ ﮐ‬CTG

‫ ﻣﻤﮑﻦ اﺳﺖ اﻗﺪاﻣﺎﺗﯽ اﻧﺠﺎم دھﺪ ﮐﮫ ﻣﻤﮑﻦ اﺳﺖ‬CTG ‫ درک ﻣﯽﮐﻨﻢ ﮐﮫ‬،‫اﮔﺮ اﺳﺘﺨﺪام ﺷﻮم و ﺑﻌﺪا ً ﻣﺸﺨﺺ ﺷﻮد ﮐﮫ اطﻼﻋﺎت ﺻﺤﯽ ﻣﮭﻤﯽ را اﻓﺸﺎ ﻧﮑﺮدهام‬
.‫ﻣﻨﺠﺮ ﺑﮫ ﺑﺎزﯾﺎﺑﯽ ھﺮﮔﻮﻧﮫ ھﺰﯾﻨﮫھﺎی ﻣﺘﺤﻤﻞ ﺷﺪه و ﻓﺴﺦ ﻗﺮارداد ﺷﻮد‬

‫ي ﭼﯥ‬o‫ ﮐﯿﺪای ﺷﻲ داﺳﯥ اﻗﺪام وﮐ‬CTG ‫ زه ﻗﺒﻠﻮم ﭼﯥ‬،‫ي‬o‫ﻤﺎرل ﺷﻢ او وروﺳﺘﮫ ﻣﻌﻠﻮﻣﮫ ﺷﻮه ﭼﯥ ﻣﺎ د روﻏﺘﯿﺎ ﻣﮭﻢ ﻣﻌﻠﻮﻣﺎت ﻧﮫ دي ﺷﺮﯾﮏ ﮐ‬u‫ﮐﮫ زه ﭘﮫ ﮐﺎر و‬
.‫‹ﺘﻮﻧﻮ د ﺑﯿﺮﺗﮫ ﺗﺮﻻﺳﮫ ﮐﻮﻟﻮ او د ﻗﺮارداد د ﻟﻐﻮه ﮐﯿﺪو ﻻﻣﻞ ﺷﻲ‬Š‫د ھﺮ ډول ﻟ‬

Signature of Employee / Consultant

Passport photo
of Employee/
Consultant to be
stamped by Doctor Date
to confirm patient.

www.ctg.org Darya Village Hawa Shinasi Road PD9, Kabul, Afghanistan, www.ctgglobal.com 7