Name and address of contractor _________________________________

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

Nature and location of work

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Name and address of Principal _________ Employer ______________

Sl. No.

Name and surname of workman

Age and Sex

Father's/ Husband's name

Nature of Employment/ Designation

Permanent Home Address of workman (Village and Tahsil / Taluk and District)

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Local Address

Date of commencement of employment

Signature or thumb- impression of workman

Date of termination of employment

Reasons for termination

Remarks

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