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RAJASTHAN FACTORIES RULES

‘FORM No.30
(Prescribed under Rule 100)
Counterfoil........... S.No.....................
Date :-------------- Date :--------------
Certificate of Fitness for Dangerous operations

1.S.No................. 1.I, certify that I have personally


examined................................................
(NAME)
2. Name of person examined------------------- S/o..............................................................

3. Father’s name............................... Residing at......................................................


(Address)
4.Sex................................................ Who is desirous of being employed?
In .....................................................................
(Name of Factory)
5.Address.............................. As......................................................................
(Department/Process)
and as nearly as can be ascertained
from examination is fit/unfit for employment at
the above noted factory
6. Name of the Factory in which 2. He is fit to be employed and may be employed
employed/ in which wished to be on some other non hazardous operation such as
employed................................... ............................................................................
7. Process of department in which 3. He may be produced for further examination
Employed /wished to be employed after a period of ...............................................
.............................................................
8.whether certificate granted? ................. 4. He is advised following further
examination ....................................................
9. whether declared unfit and certificate 5. He is advised following .
Refused?.............................................. treatment .........................................................
10.Reference number of previous
certificate granted or refused?............. 6. The S. No. of the previous Certificate is------- ---

............................................... .........................................................................
(L.T.I OF Person Examined). ( L.T.I. of Person Examined)
.
Sig. of Certifying Surgeon ------------- ------- Sig. of Certifying Surgeon--------------------------

NOTE 1.The counterfoil should be retained by the Certifying Surgeon and


maintained in a file
2. The Para which does not apply may be cancelled.
____________________________________________________________________________
1. Substituted vide Notification No.F-2(3)(9)L&E/65,dated 20.11.1968,
published in Gazette,Part. IV(C) dated 20.3.1989.

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