Form No. 5 (Prescribed under Rule 14) Certificate of Fitness 1. Serial No
. Date
. 2. Name
. 3. Fathers Name
. 4. Sex
. 5. Residence
. ................................................................... 6. Date of Birth, if available and / or age Certified
. 7. Physical Fitness
. 8. Descriptive marks
. 9. Reason for - (1) refusal of certificate
........
....................................................................... (2) Certificate being revoked
.or
.............. ............................................................................................................. ............................................................................................................. Thumb Impression Initials of Certifying Surgeon Serial No.
. Date
. I hereby certify that I have personally examined Name
.
.
...................
.
.
...................
.
.
...................
.
.
..................
.
.
...................
.
.
................... Son / Daughter
.
.
...................
.
.
................... Residing at
.
.
...................
.
.
...................
.
.
................... who is desirous of being employed in a factory, and that his / her age, as nearly as can be as curtained from my examination, is
years; and that he/ she is fit for employment in factory as an adult / child. His/ her descriptive marks are................................................................................................. ........................................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... Thumb Impression Certifying Surgeon Note.- Exact details of cause of physical disability should be clearly stated. Vide Notification No. F.1(135)/53-I & L (ii) dated 25th June, 1957. | 
