Form 1

[See rule – 18 and rule – 41 (1), (2) and (3)]

Name of Establishment :

Name of Employer :

Name of the Owner :

PAN /TAN of the Employer : :

Labour Identification Number (LIN):

Sr. no in Name Designation/ Duration Wages Total Total Rates of Wages

Employee of the Department of period no. of Overtime

Basic DA Allowance

Register Employee payment From - days (hours

of wages To worked worked or

(Monthly/ during production

Fortnightly/ the in case

Weekly/ period of piece

Daily/ workers)

Piece rated)

1 2 3 4 5 6 7 8 9 10

Overtime Nature Amount Damage or Amount of Total Date of Attendance

earning of acts and of fine lost caused to deduction amount Payment

Date Signature

omissions imposed the employer from wages of wages

for which by neglect or paid

fine default of the

imposed employee

with date

11 12 13 14 15 16 17 18 19