FORM 6
CERTIFICATE OF FITNESS
Serial No
Date
Name
Father's Name
Sex		Age		Date of Birth
Permanent Address
Present Address
Identification mark		1)
		2)
I herby certify that I have personally examined ___________________________________ son/daughter of ___________________________________ who is desirous of being employed in factory, and that his/her age as nearly as can be ascertained from my examination is _______ years and that he/she is fit for employment in factory as an adult.
Reason for
1) Refusal of Certificate:
OR
2) Certificate being revoked
Left Hand Thumb Impression			Factory Medical Officer's Stamp & Signature

FORM 23
Special Certificate of Fitness
(In respect of persons employed in occupation involving use of * compounds)
Serial No		Dated
Shri
Residing at
who is desirous of being employed as in the and that his age, as nearly as can be ascertained from my examination is years and that he is in my opinion fit for employment in operation of
		*Chromium Compounds
		*Glass Manufacturing
		*Nitro amino compound
		*Hydrogen sulphide
		*Manganese & it's compounds
		*Benzene
Identification mark		1)
		2)
Left Hand Thumb Impression		Factory Medical Officer's Stamp & Signature