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 of workman

Father's/Husband's Name

Sex

Designation/nature of employment

Date on which overtime worked

1

2

3

4

5

6

Total overtime worked or production in case of piece- rated

Normal rates workman

Overtime rate of wages

Overtime earnings

Date on which overtime wages paid

Remarks

7

8

9

10

11

12