Labour Commissioner Government of NCT of Delhi

[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