FORM XV SERVICE CERTIFICATE (See Rule 77) Name and Address of ................ Name and Address of Contractor establishment in /under Which contract is carried on ........... ........... Nature and location of work ............ Name and Address of the ........... Name and Address of Workman ............ Principal employer .... Age or Date of Birth ............ Identification Marks ............ Father's / Husband's name ............ Sl. No. Total period for which employed Nature of work done Rates of wages (with particulars of unit in case of piece- work) Remarks From To 1 2 3 4 5 6 Signature of Contractor Page 68 of 151
