| Name ani Which contracts carried on Name and address of Sub-Contractor under which Workmen Employed Name and address of Principle Employer Name and Address of workmen Age or Date of Birth Fathers/Husbands name Serial number (Token No.) Total period of which employed Nature of work Rate of Wages (Per Day) Remarks: 1) Efficiency 2) Attendance 3) Conduct Reason of Termination UAN:- Date: 24.08.2019 Place: Panaji Coron Kamen Cla (Signature of Workman) _ M/s.APEX LOGISTICS MANDOVI RIVER CARLE STAY BRIDOR PROJECT(PANAST FORM XV_ (See Rule FORM XXIV (See Rule 241(2)(b) ) Under B.0.6.W. (RIE Service Certificate 77) Under Cor d address of establishment in under enct Labour (RM A) Act 1970 and 8) Act 1996 : M/s Larsen & Toubro Ltd. Heavy Civil - Infrastructure IC 014 Bombay Bu M/s. APEX LOGISTICS 14/B,3rd Floor,Sane UdyoB Road,Andheri(East) i Panchayat Estate,Parsi 1s Development Corporation Indie Jo Infrantructurt Panajl 1 Goa Road, 7 th Floor,EDC house,Dr.Atmaram Borkar : SAVAN KUMAR SINGH VILL-BARAHI CHINTAMAN,PO-BOKTHA DIST-SITAMARHI STATE- BIHAR, PIN-843315 1 05.05.1990 1} PRAMOD SINGH : 305 14.11.2016 TO 24.08.2019 : SURVEY ASST : 453(SKILLED) + Very Good / Good / Fair : Regular / Irregular : Very Good / Good / Fair : Retrenched / Resigned / Terminated 100973506142 For M/s. Apex Logistics