Rule Form XX Form XX

FORM-XX (See rule 76) REGISTER FOR LEAVE WITH WAGES

Part I - Adults Part II - Adolescents

Establishment: Name of worker :

Department : Father's Name:

Sl. Sl.no. in the Date Interruptions Leave Whether Date from Wages for Discharged Leave Remarks of Sickness and due leave not which the Leave Paid worker No register entry accidents with desired worker is in Date of into effect during the allowed Discharge of workers service 4 from next 12 leave months 13 Authori Lock Out Involuntar Others Date and amount Accumulated sed or Legal y of payment made in carry forward Leave Strike unemploy lieu of leave due leave ment

1 2 3 5 6 7 8 9 10 11 12 14 15 16

Note: - Separate page shall be allotted to each worker

Signature of Employer/Register Keeper/Representative