Form Mpf(S) - W(M) - Certificate Of A Person'S Permanent Unfitness For A Particular Kind Of Work

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Annex B to IV.4
FORM MPF(S) - W(M)
MANDATORY PROVIDENT FUND SCHEMES ORDINANCE (CAP. 485)
CERTIFICATE OF A PERSON’S PERMANENT UNFITNESS
FOR A PARTICULAR KIND OF WORK
Name of the patient: _________________________________________________________
#
Hong Kong Identity Card/Passport*
No. of the patient: _____________________________
Based on the information provided by or on behalf of the above patient, he/she* performs the
following kind of work in his /her* present/last* job:
___________________________________________________________________________
___________________________________________________________________________
I certify that the above patient is permanently unfit to perform the above kind of work for the
following reason(s): _________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Signature of registered medical practitioner/
registered Chinese medicine practitioner*: ________________________________________
Name in block letters: ________________________________________________________
Telephone number: __________________________________________________________
Address: __________________________________________________________________
Date: ________________________________________________________
Official seal / registration number* (if any): _________________________
* Delete whichever is not applicable
#
The patient should give the passport number ONLY when he/she does NOT possess a Hong Kong Identity Card
Version 11 – June 2015

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