Form XXIX

[(See Rule No.-75(2)]

Certificate of Fitness for Dangerous Operation/hazardous process industries

1. Serial Number–

2. Name of person examined–

3. Father’s name –

4. Sex –

5. Address–

6. Name of the factory in which employed/in which wishes to be employed–

7. Process of department in which employed/wishes to be employed–

8. Whether certificate granted–

9. Whether declared unfit and certificate refused–

10. Reference number of previous certificate granted or refused–

L.T.I of person examined. Signature of medical officer Serial Number………..

I certify that I have personally examined (Name)

…………………………………………………………………………

son of (Father’s name) residing at (

………………….……………………………………… ………………………………………………..…

address) who is desirous of being employed as (name of factory)

………………………………

in………………… (Deptt. & Process), that as nearly as can be ascertained from by examination, he

is fit/unfit for employment at the above noted factory.

2. He is fit to be employed and may be employed on some other non-hazardous operation such as-

3. He may be produced for further examination after a period of-

4. He is advised following further examination -

5. He is advised following treatment -

6. The serial number of the previous certificate is-

L.T.I of person examined.

Signature of medical officer .

Note :-

1. The counterfoil should be retained by the medical officer and maintained in a bound book or

in a file.

2. The Para which does not apply may be cancelled.

By Order of the Governor of Bihar,