श्रम आयुक्त 
(PRESCRIBED UNDER RULE 86)
NOTICE OF PERIODS OF WORK FOR CHILD WORKERS
| Serial No. | Name | Father's Name | Residential Address of Child worker | Date of first employment | Number of certificate and its date | Token Number giving reference to the Certificate | Letter of group as in Form No. | Number of relay, if working in shifts | Remarks |
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |