Issued at the Port of .................................. Date ................................. Signature of Seaman or left hand thumb Impression ..........................} Shipping Master. *Strike out as necessary. (1) Medical Roster ... required
No. of Voyages
Signature of seaman or Issued on-left and thumb impression.
Ability
Conduct
Voyages Not Completed .......................................
Steamers
No. of Voyages
Rating
benefits derived and other action as per law.
---------------------------(Signature or left thumb impression of person with disability, or of his/her legal guardian in case ... Seal of Member
Name and seal of the Chairperson
Signature/Thumb impression of the person in whose favour disability certificate is issued
[Form-IV] [Inserted
described above, with my photograph affixed and authenticated. Signature or Left hand thumb impression of applicant and date ........................... [Form B] [rule 4(3)] Government ... tify that Shri ................................Son of Shri .........................whose signature and/or left hand thumb impression and photograph are attached and whose particulars are entered herein
pensioner is alive. The certificate must bear the signature or the left thumb impression of the pensioner taken in the presence of that officer ... from the pensioner to the representative bearing the signature or the left thumb impression of the pensioner together with a specimen of the signature
Name and relationship of next of kin and address
Signature or left thumb impression of the crew
Signature or left thumb impression of owner ... true to the best of my knowledge and belief.
Signature or left thumb impression of Owner/Tindal Date
register, and it shall be maintained in triplicate. Signature or left hand thumb impression, and, if practicable, a photograph of the habitual offender concerned shall
Name:- Address:-
Date :- / /20
Signature or left hand thumbimpression of the applicant.
Signature or left thumb impression if the occupants or joint occupants or superior
applicant) (*Please affix left Hand Thumb impression in case of Male and Right Hand Thumb Impression in case of Female) For office use only
From ... accuracy. (Signature/T.I of applicant) (* Left Hand Thumb Impression if Male- and Right Hand Thumb Impression if Female) Date.................. Place.................... 28. Particulars of person
Police Station ... District ... (b) Manner in which required to report (7) Left thumb impression of the habitual offender. (8) Signature and designation of the Officer ... from which leave was granted and the date of issue. 10. Left thumb impression of the person granted leave.
Signature of the Officer issuing
work in industries specified in Schedule 'A'. Signature or left thumb impression of applicant. Marks of Identification- (1) (2) Examiner. Place......... Date.......... This certificate ... that he was not then suffering from Silicosis. Signature or left thumb impression of the workman. Marks of identification. (1) (2) Place .............. Date .............. Signature
