Form No. 28 (Prescribed under Schedule VI to Rule 95) SPECIAL CERTIFICATE OF FITNESS (In respect of persons employed in operations involving use of lead compounds) Serial No
.. Dated
I hereby certify that I have personally examined
son of
....................................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 at work involving the use of lead compounds. His descriptive marks are.-
..
Left thumb impression of person examined |
Certifying Surgeon I certify that I examined the person mentioned above on | I extend that Certifying Surgeon | Signature of Certifying Surgeon | Note, of symptoms of lead poisoning (if any) | | | | |
| 
