FORM No.5 (Prescribed Under Rule 17) Certificate of fitness 1. Serial No. ________________________ Serial No. _______________________ Date_____________________________ Date____________________________ 2. Name ____________________________ I certify that I have personally 3. Father's Name _____________________ examined (name) 4. Sex_______________________________ _______________________________ 5. Residence _________________________ Son/daughter of 6. [Date of Birth if available and/or certified _______________________________ Age]________________________________ Residing________________________ 7. Physical Fitness _____________________ Who is desirous of being employed in 8. Descriptive marks____________________ a factory and whose date of birth as ______________________________________ produced in the age certificate is ______________________________________ ________________________________ 9. Reason for__________________________ as certained from my examination is (i) refusal of Certificate _________________ ___________________ years and (ii) Certificate being revoked____________ he/she is fit for employment in ______________________________________ factory as an adult/child. ______________________________________ His/Her descriptive marks are ________________________________ ________________________________ Thumb Thumb Impression Impression Initials of Certifying Surgeon Certifying Surgeon Page 114 of 151
