Name and address of contractor

__________________________________

Name and address of establishment in

/ under which contract is carried on

____________________

Nature of work and location of work

__________________________________

Name and address of Principal Employer

_________________________________

1.Name of the workman

________________________

_________________________________

2.Sl. No. in the register of workmen employed

___________________________________

_________________________________

3.Nature of employment / Designation

_________________________________

_________________________________

4.Wage rate(with particulars of unit , in case of piece- work)_____________________

_________________________________

5.Wage period _______________

_________________________________

6.Tenure of employment _______________________

_________________________________

7.Remarks __________________

_________________________________