FORM NO. 5 ENDORSEMENTS [Prescribed Under Rule 14] Certificates of Fitness 1. Name & Address of the Factory 2. Serial No. 3. Name 4. Father's Name 5. Sex 6. Residence 7. Dateof Birth / or certified age 8. Physcial Fitness 9. Descriptive marks 10. If already employed, Nature of work 11. Raw materials or by products handled 12. Date of employment on present Work 13. Result of last Medical Examination, if any: 14. Result of present Medical Examination/ Symptoms and signs observed. 15 If suspended from work, state period of with detailed reasons. 16. If recertified, fit to resume duty on 17. If certificate of unfitness or suspension issued to worker. 18. Date of leaving or transfer with reasons for discharge or transfer. 19. Certificate extended upto 20. He is advised following further examination/treatment 21. I hereby certify that i have personally examined................................................S/D/W of .......................................residing at .............................................................................. ................................................................who is desirous of being employed in a factory and that his/her age as nearly as can be ascertained from any my examination, is.............. ..............................................years and he/she is fit for employment in factory as on adult/child in Mfg/handing process viz............................................................................. His/Her descriptive marks............................................. Signature of Certifying Surgeon. Signature/Thumb Impression of worker. ....................................................................... 22. Reasons for 1. Refusal of certificate 2. Certificate being revoked. Place : Date : Signature of Certifying Surgeon
