FORM A
[Rule 3]
MUSTER-ROLL

Name of mine or circus
1. Serial number
2. Name of woman and her father's (or, if married, husband's) name
3. Date of appointment
4. Nature of work
5. Dates with month and year in which she is employed, laid off and employed

Month	No. of days employed	No. of days laid off	No. of days not employed	Remarks

6. Date on which the woman gives notice under section 6
7. Date of discharge/dismissal, if any
8. Date of production of proof of pregnancy under section 6
9. Date of birth of child
10. Date of production of proof of delivery/miscarriage/2[Medical termination of pregnancy/tubectomy operation/death]
11. Date of production of proof of illness referred to in section l0
12. Date with the amount of maternity benefit paid in advance of expected delivery
13. Date with the amount of subsequent payment of maternity benefit
14. Date with the amount of bonus, if paid, under section 8
15. Date with the amount of wages paid on account of leave under section 9
3[15A. Date with the amount of wages paid on account of leave under section 9A]
16. Date with the amount of wages paid on account of leave under section 10 and period of leave granted
17. Name of the person nominated by the woman under section 6
18. If the woman dies, the date of her death, the name of the person to whom maternity benefit and/or other amount was paid, the amount thereof, and the date of payment
19. If the woman dies and the child survives, the name of the person to whom the amount of maternity benefit was paid on behalf of the child and the period for which it was paid
20. Signature of the employer of the mine or circus authenticating the entries in the muster-roll
21. Remarks column for the use of the Inspector
3. Inserted by GSR 70(E), dated 31st. January, 1996, w.e.f.1st. February, 1996.