[Form in which to furnish particulars in respect of recruitment and employment of migrant workman workmen as prescribed under sub-rule (1) of rule 21, to the authorities specified under the Explanation below subsection (2) of section 12 of Inter-State Migrant Workmen (Regulation of Employment and Conditions of Service) Act, 1979.]
1. Name and address of the contractor.
2. Name and address of the sub-contractor through whom recruitment has been made.
3. Name and address of the establishment.
4. Name and address of the Principal Employer.
5. Name of the State in which the place of work is located.
6. Name of the State in which recruitment was made.
Serial Number
Name of migrant workman.
Father’s /Husband’s Name
Sex.
Age
Permanent home address.
Name and address of the next of kind of the migrant workman
Place and address of residence in the home State.
Amount of displacement allowance paid.
1
2
3
4
5
6
7
8
9
Amount of outward journey allowance paid.
Amount of wages for outward journey period paid.
Nature of job required to be performed
Date of recruitment
Date of employment
Details of rates of wages and other allowances payable
Period of contract of employment
Details of other service conditions
Remarks
Signature of Contractor or his
authorised representative
Date:
Submitted to
(1).............…………….
(Specified authority in the State from which the migrant workman/workmen is/are employed).
(2)...................................
(Specified authority in the State in which migrant workman/workmen has/have been recruited.)
Copy forwarded to
.................………..
(The Principal Employer)
Signature of the Contractor or his
authorised representative.
Date:
NOTE: In case where migrant workmen concerned have been recruited from more than
one State, separate returns shall be submitted in respect of each such State.
