[Prescribed under Rule 53]

1. Name of the worker.
2. Serial number as in the register of workers under Section 62 of the Act
3. Father's name
4. Age and date of birth.
5. Nature of work
6. Qualifications, if any, period of service on similar work.
7. Remarks

  I certify that the above mentioned worker is a properly trained male adult worker who is competent to mount or shift belts, lubricate or do other adjusting operations, on machinery installed in my factory while they are in motion.


Date                                                                                             Signature of Occupier