FORM ‘C’ [See in Rule 5(1)] This is to certify that I examined ____________ wife/daughter of ________________ a woman employed in ______________ (name of the establishment) on __________ (date) and found/cannot discover that she is pregnant and is expected to be delivered of a child within _______________ (month/days) from the above mentioned date/has undergone miscarriage/has been delivered of a child on ___________ (date) from illness arising out of pregnancy/delivery premature birth of a child or a miscarriage. Dated________________ Signature, Qualification, Designation of Medical Officer/ Medical Practitioner.
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