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FORM XV

(See Rule 77)


Service Certificate
Name and address of Establishment / in : Larsen & Toubro Limited, TI IC
Under which contract is carried on. Mumbai-Ahmedabad High Speed Rail-
Package-C6
TFL Office, 6TH Floor, Lilleria 1038, Gotri-Sevasi Road,
New Alkapuri, Laxmipura, Vadodara, Gujarat - 390021.

Name and address of Principal Employer : National High Speed Rail Corporation
Limited, 3rd Floor, Productivity House, Productivity
Road, Alkapuri, Vadodara,Gujarat – 390007

Name and address of Contractor : Larsen & Toubro Limited, Construction Transportation
Infrastructure, Construction Skills Training Institute, Plot No.
144-146, Sarkhej Bavla Road, Chacharawadi Mata Mandir
Patiya, Ahmedabad, Gujarat -382 213, INDIA

Nature and Location of Work : Construction of Mumbai-Ahmedabad High


Speed Rail- Package-C6, Between Vadodara &
Ahmadabad from Km 401.898 to Km 489.467.

Name and address of Workman : SHIVA SINGH


VILL:- PENDA, PO:- BAHAR
DIST:- HARDOI, UTTAR PRADESH - 241001

Age or Date of Birth : 19-07-2002


Identification Mark : No mark.
Father’s / Husband’s Name : SANTOSH KUMAR SINGH
Wisa Id : 1311734
Total Period for which Employed From : 12.01.2022 To 12.01.2024
Nature of Work Done : CIVIL SUPERVISOR
Rate of Wages (with particulars of unit : Rs.692 (Skill)
in case of piece work)
Remarks: - 1. Efficiency : Good / Fair / Satisfactory
2. Attendance : Regular / Irregular
3. Conduct : Good / Fair / Satisfactory
Reason for Leaving of Service : Training completion / Retrenched / Resignation
Account Number :
UAN No. :
………………………
Signature of Workman
Place: - for M/s. Larsen & Toubro Limited, Construction
Transportation Infrastructure, Construction
Skills Training Institute
Date: - (Authorized Signatory)

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