Name and address of contractor _____________

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

Nature and location of work _________________

Name and address of Principal employer _____________________________________ Wage period : Monthly ____________

Sl. No.

Name of workman

Serial No. in the register of workman

Designation / nature of work done

No. of days worked

Units of work done

1

2

3

4

5

6

Daily-rate of wages/piece-rate

Amount of wages earned

Basic wages

Dearness allowances

Overtime

Other cash payments (Nature of payment to be indicated)

Total

8

9

10

11

12

7

Deductions, if any (indicate nature)

Net amount paid

Signature /Thumb impression of workman

Initial of contractor or his representative

13

14

15

16