FORM XV Service Certificate

[Rule 77]

Name and address of establishment of

Name and address of ___________________
in/under which contract is carried
contractor
on ____________________________

Name and location of work

_______________________

Name and address of the _______________

Name and address of principalemployer_____
workman _________________________

Age or Date of Birth______________

Identification marks ___________________

Father's /Husband's name _____________

Rate of wages
Nature of work (with particulars
Sl. No. Total period for which employed Remarks
done of unit in case of
piece-work)

From To

1 2 3 4 5 6

Signature of contractor