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[接上页] ................................................ Signature of applicant. Declared at ................................................... in Hong Kong this ......................... day of .................................... 19 ....... Before me, ............................................. Notary Public, or Commissioner for Oaths. ----------------------------------------------------------------------------------------------------------------- (1) Full details of the nature of the work and duties on which the employee was employed at the date of the accident. (2) Give full details and state whether incapacity is total or partial, permanent or temporary. If partial, the degree, and, if temporary, the period of actual or estimated incapacity must be given. (3) The monthly earnings must be stated, specifying the value of food, fuel or quarters if the employee has been deprived thereof as a result of the accident. (See sections 3 and 11 of the Ordinance.) (4) Copy of certificate as determined by the Commissioner for Labour must be attached. (L.N. 383 of 1995; 36 of 1996 s. 30; 47 of 1997 s. 10) (Schedule replaced L.N. 208 of 1983) |