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FORM XV : SERVICE CERTIFICATE

[Rule 77]

Name and address of_________________

_________________________ contractor

Name and address of establishment of in/under which contract is carried on __________________________

Name and location of work____________

_______________________

 

Name and address of the

__________________________________ workman ___________________

Name and address of principal employer________________________

Age or Date of Birth

_____________________________

 

Identification marks______________________________

 

Fatherís /Husbandís name

________________________

 

 

Sl. No.

Total period for which employed

Nature of work done

Rate of wages(with particulars of unit in case of piece-work)

Remarks

 

From

To

 

 

 

1

2

3

4

5

6

 

 

 

 

 

 

Signature of contractor



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