FORM XV
(See rule 77)
Service Certificate
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--------------------------------------------------
Name and address of the
workman-------------------------------------------------------
Age or date of
birth---------------------------------------------------------------------
Identification
marks---------------------------------------------------------------------
Father's/Husband's
name.-------------------------------
| Sr. No. |
Total period for which employed From To |
Nature of work done |
Rate of wage (with particulars of unit in case of piece work) | Remarks | |
| 1 | 2 | 3 |
4
|
5 | 6 |
Signature----------------