CERTIFICATE

I, ---_________________________,, proprietor of ---_________________________,, duly

certify that the following are the employees of the said
establishment:

1. _____________________________ 11. _________________________

2. _____________________________ 12. _________________________
3. _____________________________ 13. _________________________
4. _____________________________ 14. _________________________
5. _____________________________ 15. _________________________
6. _____________________________
7. _____________________________
8. _____________________________
9. _____________________________
10. ____________________________

---_________________________,
Proprietor