Labour Commissioner 
(PRESCRIBED UNDER SCHEDULE VI TO RULE 95)
SPECIAL CERTIFICATES OF FITNESS
(In respect of persons employed in operations involving use of lead compounds)
Serial No.........
Dated.........
I hereby certify that I have personally examined ............. son of ........................................residing at ................. Who is desirous of being employed as ......................in the .................and that his age .................as nearly as can be ascertained from my examination, is ................years, and that he is, in my opinion, fit for employment at work involving the use of lead compounds.
His descriptive marks are :-
.................................................................... ....................................................................
Left thumb impression of person examined
Certifying Surgeon