all applicants for the postal service must have this certificate executed.

questions 1, 2, 3, 7, 8, 9, and the parenthetical part of question 13, are not required in the case of female applicants.

this certificate need not be executed for examinations at second and third class post offices. when the result of examinations at such offices is determined, the highest four eligibles will be required to furnish the certificate.

applicants for the postal service (male and female) who are defective in any of the following-named particulars will not be appointed by that department: deaf-mutes, hunchbacks, persons having defective hearing, sight, or speech; persons totally blind or blind in one eye; one-armed, one-handed, or one-legged persons, or those having crippled arms or legs, and those suffering from asthma, consumption, or hernia. the applications of such persons will, therefore, not be accepted.

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1. what is the applicant’s exact height in his bare feet? (the physician must himself measure and weigh the applicant.)

2. what is the applicant’s exact weight in his ordinary clothing, without overcoat or hat?

3. did you yourself weigh and measure the applicant?

4. what is the condition of the applicant’s sight? (if possible, the test should be made with snelen’s cards, and expressed in twentieths.)

if the applicant has any defect of sight in either eye, describe fully.

is the defect in sight corrected by the use of glasses?

5. what is the condition of the applicant’s hearing? (state the distance, in feet, at which he can hear the ticking of a closed watch held in the open hand, testing each ear with the other plugged.)

if he has any defect of hearing of either ear describe fully.

6. what is the condition of the applicant’s speech? if he has any defect of speech describe fully.

7. what is the condition of the applicant’s limbs?

if he has any defect in either arm or in either leg describe fully, and state to what extent it interferes with the proper function of the limb.

(varicose veins, ulcers, or any deformity should be specially reported.)

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8. has the applicant any rupture?

9. has the applicant varicocele, hydrocele, internal or external piles, fistula in ano, or any cutaneous disease?

if so, describe the disease, and state to what extent the applicant is afflicted.

10. has the applicant any defect in the functions of the brain or nervous system?

if so, describe the disease, and state to what extent the applicant is affected.

has the applicant ever had an epileptic fit?

is he subject to these attacks?

11. give the measurements of the applicant’s chest:

at rest.

at full inspiration.

at full expiration.

12. is the applicant’s respiration full, free, and unobstructed in both lungs?

if not, state to what extent obstructed.

13. state the frequency of the action of the applicant’s heart:

when sitting.

when standing.

when standing after brief exercise. (the applicant should be required to hop on one foot the distance of about 12 feet.)

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14. are there indications in the heart’s action of organic, muscular, or nervous derangement?

if so, describe fully.

15. are there indications that the applicant is addicted to the excessive use of intoxicating beverages, tobacco, or narcotics in any form.

if so, describe fully.

16. has the applicant any form of disease or disability which is likely to unfit him for the performance of the work of the position for which he applies?

17. state whether the applicant is capable of prolonged, severe, mental and physical exertion, and equal to the demands of a very exhausting occupation.

18. are you a regularly licensed physician, and duly authorized by the laws of your state to practice medicine?

19. of what medical institution are you a graduate?

this space is to be filled out by the applicant in his own handwriting, in the presence of the physician.

(signature of applicant) ................

i certify that i have made a thorough examination of the above-named applicant, that each and all of the above answers are in my own handwriting and are true, and that the applicant wrote his signature just above in my presence.

(signature of physician) ....................

(p. o. address of physician) ................

date, ............., 190..