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 _____________

Sl. No.

Total period for which employed

From

To

Signature of contractor

Rate of wages
Nature of work (with particulars
Remarks
done
of unit in case of
piece-work)