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Bare acts > Punjab Maternity Benefit Rules, 1967 > Form C
 
  


 

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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