Form 10 [See rule 25(2)] CERTIFICATE OF FITNESS 1 (a) Serial no (b) date 2. Name of the Person examined 3. Father's Name 4. Sex 5. Residence 6. Date of Birth 7. Physical fitness 8. Descriptive marks 9. Reason for a) refusal of Certificate b) Certificate being Signature or left hand thumb impression of the person examined Initials of Certifying Surgeon Serial No Date I Certify that I have personally examined Sri/Smt .................. Son/daughter of ........... residing at .............. .................. .................. .................. .................. who is desirous of being employed in a factory, and that his /her age, as nearly as can be ascertained from my examination is ... yrs, and that he/she is fit for employment in factory as an adult/child. His/Her descriptive marks are ........ .................. .................. .................. .................. Signature or left hand thumb impression of the person examined Signature of Certifying surgeon
