1

Serial number

2
Name

Fathers/Mothers

3
name

Residential address

4
of the worker

Date of birth

5
Date of first
6 employment

No. of certificate
7

and its date

FORM -14

Token No. giving

8

reference to
certificate
(Prescribed under Rule 113)

REGISTER OF CHILD WORKERS

Letter of groups as
9

in Form

No. of relay, if
10

working in shifts

Remarks
11