FORM III

[See Rule 10]

Certificate to be Furnished by a Person to his Employer

I,__________________________________________________________________________(Name)
_________________________________________________________________________________
_______________________________ (Address) hereby certify that I am engaged in the *profession/
trade / calling of _______________________________________________________ specified in
the___________________________________ Schedule I appended to the Andhra Pradesh Tax on
Professions, Trades, Callings and Employments Act, 1987 and that the rate of tax payable by me under
the said entry, namely Rs. ________________ Per annum is more than the rate of tax payable by me
under Entry I in the said schedule in respect of employment with,
_________________________________________________________________________________
(Name of the employer)
_____________________________________________________________________________________
_________________(his address)

I also certify *I shall get myself enrolled and shall pay the Tax / I have got myself enrolled under
enrolment certificate.No ___________________________ dated _____________ and I have paid the
*tax/shall pay the tax.

Place :Date :

Note : *Strike out whichever is not applicable

(Signature)