Labour Commissioner 
[PRESCRIBED UNDER RULE 53 (A)]
P ART I
1. Name of the Worker .......................................................................................
2. Serial No. as in the register of workers, under section 62 of the act .......................................................................................
3. Father's Name .......................................................................................
4. Age and date of birth .......................................................................................
5. Nature of work . .......................................................................................
6. Qualifications, if any, or period of service on similar work .......................................................................................
7. Date when tight fitting clothing were provided .......................................................................................
8. Signature or thumb impression of workers .......................................................................................
9. Remarks .......................................................................................
SIGNATURE OF OCCUPIER