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 ___________________________________

Sl. No.

Name

Father's/Husband's name

Nature of employment/Designation

Wage period and wages payable

Date and amount of advance given

1

2

3

4

5

6

Purpose(s) for which advance made

No. of installments by which advance to be repaid

Date and amount of each installment repaid

Date on which last installment was repaid

Remarks

7

8

9

10

11