CERTIFICATE OF EMPLOYMENT PROOF BY SELF (Worker)

[U/r 265(2) (iii) of OB & OCW (RE & CS) Rules-2002]

TO WHOM IT MAY CONCERN

This is to certify that I Sri/ Smt.:…………………………………………………………..
S/D/W/of……………………………………………………………………………………………
ofVillage/Ward:………………………………Po………………………………Ps………………G.P/NAC/Muni
cipality:………………………………Block:……………………………………. Dist: …………………… am a
construction worker and I am basically (Nature of Job)……………………
I, do hereby declare that I have worked for 90 days or more under different employers/establishments in
different periods of the preceding twelve months as specified below.
Work report of the worker for preceding twelve months
Sl Name , Address of the Contact/Mob No Period of Employment Total Days
No. Employer/Establishme (if known) Employed
nt & Registration No Date from Date upto
(if any)
1

10

Certified that the submission made above are true and correct. For any discrepancy in above
information I shall be held responsible personally as per law.
Place-
Date-

Signature/Thumb impression of the Applicant