श्रम आयुक्त 
RULE PRESCRIBED UNDER SECTION 107
CERTIFICATE OF FITNESS
(1) Serial No........................................... Serial No......................................
Date .............................................. Date .............................................
(2) Name ............................................ I hereby certify that I have personally examined Name ......................................................
(3)Father's Name ................................. ............................................................
(4)Sex ................................................... ................................................................
(5)Residence ................................................. Son/ Daughter ..........................................
(6)*Date of Birth, if available and / or age Certified.................................................................
(7)Physical Fitness ....................................... ...............................................................
(8)Descriptive marks ..................................
................................................................ who is desirous of being employed in a factory, and that his / her age, as nearly as can be as curtained from my examination, is .................. years; and that he/ she is fit for employment in factory as an adult / child.
(9)Reason for -
(1) refusal of certificate .......................
(2) Certificate being revoked ...............or............
His / her descriptive marks are ...............................
.................................... ...............................
.............................. ...............................
Note:- Exact details of cause of physical disability should be clearly stated.
* Vide Notification No. F.1(135)/53-I & L (ii) dated 25th June, 1957 .