FORM XVII [See Rule 78(1) (a)(i)] Register of Wages Name and Address of Contractor ...

Nature and location of works ... Name and address of Establishment in / under which contract is carried on . ... Name and address of Principal Employer Wage period: Monthly ... No. of days worked 5 Units of works done 6

Sl. No. 1

Name of workman 2

Serial No. in the register of workman 3

Designation / nature of work done 4

Daily-rate of wages/piece rate 7

Basic wages 8

Amount of wages earned Dearness Overtime Other cash payments Allowances (Nature of payment to be indicated) 9 10 11

Total 12

Deductions, if any, (indicate nature) 13

Net amount paid 14

Signature / Thumb impression of workman 15

Initial of contractor or his representative 16