OHC/H3

FORM No 4 - CERTIFICATE OF FITNESS

Karnataka Factory Rules 1969[88-L (2)]

Name of the factory

Address
Serial number

I certify that I have personally examined (Full Name) ………………………………………….......……… son of

(Father Name)……..………………………..………...…….…………………………….……………… residing at

(Full Address) …………....…………………………..….….……………………………………………………………

………………………………………………………………….……………………..……………… who is desirous of

being employed as (Designation) …………………………….………………….……………………………..…… in

(Process, Department and factory)..……………………………... and that his age, as nearly as can be

ascertained from my examination is (age) …………………..….… years, and that he is, in my opinion,

(Fit/Unfit)……………..………………. for employment in the above mentioned factory as mentioned above.

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

The serial number of the previous certificate is……………………………………………………..

Signature or left hand thumb Signature of factory medical officer

Impression of the person examined Date:

I certify that I have I extend this certificate

Examined the person Until (if certificate is not extended, the Signature of the
mentioned above on period for which the worker is Signs and symptoms certifying
considered unfit for work is to be observed during surgeon
mentioned) examination