1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Serial Number

Name of person examined

Father’s Name

Sex

Address

Name of the factory in which employed/in which Wishes to be employed

Process or department in which employed/wishes to be employed

Whether Certificate granted

Weather declared unfit and certificate refused

Reference number of previous certificate granted or refused

 L.T.I. of person examined.

…………………………………………

Signature of Certifying

Surgeon

Serial Number …………………………..

I certify that I have personally examined ……………………………( name) son of ……………….
………………….residing at …………………………………………………………….

(father’s name) …………………………………………..

who is desirous of being employed as …………………………………………………………………………………

(Department and process)

in ……………………………………………………………………………………………………………………….

(name of factory)

………………………………… and that as nearly as can be ascertained from my examination, is fit/unfit, for employment at the above noted factory.

2. He is fit to be employed and may be employed on some other non-hazardous operation such as ………………….
…………………………………………………………………………………………………………………………..

3. He may be produced for further examination after a period of ……………………………………………………..

4. He is advised following further examination ……………………………………………………………………….

5. He is advised following treatment …………………………………………………………………………………..

6. The serial number of the previous certificate is …………………………………………………………………….

    L.T.I. person examined

Singature of Certifying

Surgeon …………………………

Note :- 1. The counterfoil should be retained by the certifying Surgeon and maintained  in a bound book or in file

2. The para which does not apply may be cancelled