FORM 5
(Prescribed under Rule 14)
Certificate of fitness for young person
Space for passport
Size photograph of the
young person examined
1. Serial Number
2. Name of persons examined
3. Fathers Name
4. Sex
5. Residence
6. Date of birth, if available
7. Referred by-
(a) Name and address of the factory
(b) Name of Manager
8. Manufacturing process in which young person is proposed to be employed
I certify that I have personally examined the named person whose identification marks are And who is desirous of being employed in the above mentioned manufacturing process, and that his/her age, as nearly as can be ascertained from my examination is years, and that he/she is *fit/unfit for employment in the said manufacturing process as an *adult/child.
Physical disability, if any
Reasons for refusal/revocation of certificate
...
Signature or left hand thumb Signature of Certifying Surgeon
impression of the person examined Name (in block letters)
Date :
Note : 1. To be issued by the Certifying Surgeon and a copy to be retained for 2 years.
2. As per the proviso to sub-section (2) of Section 69, the Certifying Surgeon issuing this certificate should have personal knowledge of the place where the young person proposes to work and of the manufacturing process in which he will be employed.
3. As per Section 69(3) of the Act this certificate is valid for one year from the date of issue.
4. In case of physical disability, the exact details should be clearly stated.
5. *Place delete what is not applicable
6. Young person mean a child (who has completed 14, years and not completed 15 years ) or and adolescent (who has completed 15 years and not completed 18 years of age).