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______________________________

Father's /Husband's 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