Form 37

(see rule 128 )

Certificate of Fitness

1. Serial No................. Serial No.................

Date.................... Date....................

2. Name........................... I certify that I have personally examined

(name)..............

3. Father's Name.................. …..................................

‍655

4. Sex....................... son/daughter of.............................

5. Residence........................ …..................................

6. Date of birth, if available/and certified Residing at ….......who is desirous of being employed

age............. in a factory, and that his/her age as nearly as can be

ascertained from my examination date of birth

is............years,

7. Physical fitness................ that he/she is fit for employment in factory, as an

adult

8. Descriptive marks................. His/Her descriptive marks are

…....................................

9. Reason for -

(1) Refusal of certificate

…...................................

(2) certificate being revoked

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

Initials of Medical Practitioner/Officer

Note: Exact details of cause of physical disability should be clearly stated.

[No. F-PS-HQ-RajFAB(1)F&B, Rajasthan/2018-000302]