TNAG-0585-FCO40-718-Employment-of-children-in-Hong-Kong-1976 — Page 31

1973 Ed.]

1. I, ........

Factories and Industrial Undertakings Regulations

(full name of proprietor)

(residential address of proprietor)

[CAP. 59

A 27

the proprietor of

(name of industrial undertaking)

situated at

(address of industrial undertaking)

request you to examine

(full name of Employee/proposed Employee*)

in accordance with regulation 16C(3) of the Factories and Industrial Undertakings Regulations.

2. This Employee/proposed Employee* is/will be* employed to work

underground as a

(specify nature of Employee's/proposed Employee's* occupation)

and first commenced/will commence* such work on

(specify date or proposed date)

Date:

Signature of proprietor:

Part II. (To be completed in duplicate by the Employee or proposed

Employee).

A. Full Name of Employee/proposed Employee*

Date of Birth

Residential Address

B. History of Past Illnesses.

(a) Is there a history of pulmonary

tuberculoses?

If so give details

(b) Is there a history of other chronic

respiratory disease?

(Full face photo- graph of person examined).

(c) Is there a history of heart disease, diabetes mellitus or any other

serious or prolonged disease?

C. Present Complaints (if any).

I declare that to the best of my knowledge the answers given above

are accurate.

Date:

Signature of Employee/proposed Employee*:

[Subsidiary]