TAMIL NADU FACTORIES RULES-1950 TAMIL NADU FACTORIES RULES-1950

FORM No 27 FORM No 27
(Prescribed Under Rule 95) (Prescribed Under Rule 95)
CERTIFICATE OF FITNESS CERTIFICATE OF FITNESS

1. Serial number and date : 1. Serial number and date :

2. Name of the person examined : 2. Name of the person examined :

3. Father's name : 3. Father's name :

4. Sex : 4. Sex :

A-3 Side Book Binding 3-Book (1-Book 100 Sheet) Block Color
5. Residential address : 5. Residential address :

6. Name of the Factory in which the person is 6. Name of the Factory in which the person is
: :
employed or to be employed employed or to be employed
7. Process or department in which the person is 7. Process or department in which the person is
: :
employed or to be employed employed or to be employed

8. Descriptive marks : 8. Descriptive marks :

9. Whether certificate granted i) I certify that I have personally examined 9. Whether certificate granted i) I certify that I have personally examined

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S/o.-------------------------------------------------------------------------- S/o.--------------------------------------------------------------------------

residing at ----------------------------------------------------------------- residing at -----------------------------------------------------------------

who is desirous of being employed in or employed who is desirous of being employed in or employed

in --------------------------------------------------------------------------- in ---------------------------------------------------------------------------
and that as nearly as can be ascertained from my and that as nearly as can be ascertained from my
examination is fit /unfit for employment at the above examination is fit /unfit for employment at the above
noted factory. He is fit to be employed and may be noted factory. He is fit to be employed and may be
employed on some other non-hazardous operation such employed on some other non-hazardous operation such

as---------------------------------------------------------------------------- as----------------------------------------------------------------------------
He may be produced for further examination after a He may be produced for further examination after a
10. Whether declared unfit and certificate refused 10. Whether declared unfit and certificate refused
period of------------------------------------------------------------------ period of------------------------------------------------------------------
11. Reason for : 11. Reason for :
He is advised the following further He is advised the following further
(1) refusal of certificate………(or) (1) refusal of certificate………(or)
(2) certificate being revoked examination----------------------------------------------------------------- (2) certificate being revoked examination-----------------------------------------------------------------
12. Reference number of previous Certificate granted or refused. 12. Reference number of previous Certificate granted or refused.
He is advised the following treatment. The serial He is advised the following treatment. The serial

number of the previous certificate number of the previous certificate

is------------------------------------------------------------------------------ is------------------------------------------------------------------------------

L.T.I /Signature of the person examined Signature of the Certifying Surgeon L.T.I /Signature of the person examined Signature of the Certifying Surgeon
Note: Exact details of cause of physical disability should be clearly stated. The counterfoil should be retained by the certifying surgeon and maintained Note: Exact details of cause of physical disability should be clearly stated. The counterfoil should be retained by the certifying surgeon and maintained
in a bound book or in file. in a bound book or in file.