FORM - A (See rule 3) Muster Roll Name of Establishment. 1. Serial Number. 2.

Name of woman and her fathers (or if married husbands) name. 3. Date of appointment. 4. Nature of work. . Dates with month and !ear in whi"h she is emplo!ed# laid off and not emplo!ed. $. Date on whi"h the woman %i&es noti"e under se"tion $. '. Date of dis"har%e(dismissal# if an!. ). Date of produ"tion of proof of pre%nan"! under se"tion $. *. Date of birth of "hild. 1+. Date of produ"tion of proof of deli&er!( mis"arria%e(death. 11. Date of produ"tion of proof of illness referred to in se"tion 1+. 12. Date with the amount of maternit! benefit paid ad&an"e of e,pe"ted deli&er!. 13. Date with the amount of subse-uent pa!ment of maternit! benefit. 14. Date with the amount of bonus# if paid under se"tion ). 1 . Date with the amount of wa%es paid on a""ount of lea&e under se"tion *.

1$. Date with the amount of wa%es paid on a""ount of lea&e under se"tion 1+ and period of lea&e %ranted. 1'. Name of the person nominated b! the woman under se"tion $. 1). .f the woman dies# the date of her death the name of the person to whom maternit! benefit and(or other amount was paid# the amount thereof# and the date of pa!ment. 1*. .f the woman dies and the "hild sur&i&es# the name of the person to whom the amount of maternit! benefit was paid on behalf of the "hild and the period for whi"h it was paid. 2+. Si%nature of the emplo!er of the establishment authenti"atin% the entries in the muster roll. 21. /emarks "olumn for the use of the .nspe"tor. ---------------------------------