Name and address of contractor ___________________________

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

Name and address of Principal employer ____________________________________

Wages period : Weekly/ Fortnightly ____________________________________

Nature and location of work ________________

From _______________ to ______________

Sl. No.

Sl. No. in register of workman

Name of employee

Designation / nature of work

Daily attendance units worked

Total attendance / units of work done

12. 15

1

2

3

4

5

6

Daily-rate of wages / piece-rate

Amount of wages earned

Basic wages

Dearness allowance

Overtime

Other cash payments (Nature of payments to be indicated)

Total

7

8

9

10

11

12

Deduction, if any, (indicate nature)

Net amount paid

Signature/Thumb- impression of workman

Initials of contractor or his representative

13

14

15

16