श्रम आयुक्त 
(Prescribed under Rule 85)
Notice of Periods of Work for Child Workers Name of Factory ....... Place ........... District ......
| Periods of Work | Description of groups | ||||||||
| Groups | A | B | C | ||||||
| Relays | 1 | 2 | 1 | 2 | 1 | 2 | Group Letter | Nature of Work | Remarks |
| From ....... To ........ | |||||||||
Dated on which this notice is first exhibited ............ Manager
(Signed) ..............