Sl.

No.

Name

Date of birth

Sex

Residential
address

Father’s
Husband’s
Name

Date of
appoint-
ment

Group of which
worker belongs

Number of
relay if
working
in shifts

Adolescent if
certified as
adult

Re
marks

Alphabet
assigned

Nature
of work

Number & date of
certificate
of fitness

Number
under
section

86

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)