FORM T
See rule 29P(1)

Annual Return for the year ending on the 31st December
1. Name of Mine ................................
2. Postal address of Mine ................................
3. Date of opening ................................
4. Date of closing (if closed) ................................
5. Situation of Mine (District/State)
6. Name of Owner, Postal address of owner
7. Number of persons required to be medically examined ...............................
8. Number of persons medically examined
9. Number of persons declared medically unfit
10. Categorisation of the persons declared unfit ...............................
Certified that the information given above is correct to the best of my knowledge.
Signature .........................
Designation .
Date