FORM No. 42

(Prescribed under Rule 122)

 Certificate of Fitness

Serial Number …………………………..

I certify that I have personally examined ……………………………………………..( name) son of ……..……...residing
(father’s name)

At……………………………………………………………………..………

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

(designation)

is…………………….(process, department and factory ) and that his age, as nearly as can be ascertained from my examination, is ……………………..years and that he is, in my opinion, fit/unfit, for employment at the above noted factory as mentioned above.

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

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

 

Signature/Left thumb impression                            Signature of the
of the person examine                                            Certifying Surgeon

                                                                            

Date :

I certify that I examined the person mentioned above on	I extend this certificates until (if certificate is not extended, the period for which the worker is considered unfit for work is to be mentioned)	Signs and symptoms observed during examination	Signature of the Certifying Surgeons