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AGE PROOF & FITNESS CERTIFICATE

Name of Factory
Serial No .Token noDate.............
1. Name of the Employee

2. Fathers / Husbands Name :

3. Date of Birth ( if He/She Knows):
4. Number of Teeth

5. Height & Weight

: .......Feet..Inch....Kg

6. Blood Group (if He/She Knows) :

7. If any communicable / infectious disease present?

Yes

No

This is to certify that Mr. / Mrs. / Miss...

Son / Daughter / Wife of
Vill.P.OP.S..
Dist..........................Who is desirous of being employment in this factory.
His/Her age on. .is about...Years from above
Examination and that he / she is physically fit for employment in factory as an adult. His / her
Identification mark is .

-------------------------------------------------------Thump Impression

Name & Signature of the Certifying Doctor.