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6d no$a$ 206 sudso$$ (2)d $od (n) $rod dsOet6,rrb]ilrod.b/CRADAI/BA.l/i$CA
dud odaa edd i;*,orro F;$tlaoo$O dndnacbd u{ robrdail ocabd
Form No -V (A)
[$ee clause (c).of sub-r.ule 12; of Rule 201

Dm proym e", /conrractor

".,#Yfl1ffi1fl1,oyer
/CREDAI /BAI N<Sb,t
irr:FoDddi dgd 12 eor(9o dqd $+m ,:aCd
SdErro uaoJrrdfl dndndciJ rod$riDoc$ doosdd
I f1:,lllEladd t\croF dicb iJrd: oslE
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Full narne and address of the employer/conkactor
of the building & other consrructjon work,
q.herein the applicant has wOfked as construction
rvorker during prcccding l2 montbs
I
vvl{3(rr a'9

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/KSCA ;Jo;'goJ: edo{6 n'Dobrd0F eCErD sdd
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5 \ed Sb-vGS P\Eb.<
?.* 's c.\ag3 "S con\2rrt1 r=o5'
;a;r:i:.drrDgd ddJoroF ddcb OUf(D OOi
Name and full addrcss of the
Qfuirman /Secretary
(or thc.ir nominee) of CREDAI /BAI /KSdA
issuing this certificate 6An\i :!8q tlz\ a ga>A^^:t.
(Strike ofr, if not ap,p.llcab!)
z id;orro rD&)rgd Corar dxtb
91 E\ \gos\". - c^f ^,,, o-ll-
FrLll namc of Cons.tnrction rrly'orker
b{na..r..o...
lJ i)*?Ffa r}aJrid ,Do$o As?X
1rSogL .-S ,9t . Srrcz-r{\{doJdl , .,+"'.pf
P crm an enr a ddres.,; o I Ccn s',.:".:cti o n W o rk er
R.a.i cA.^sr ()x.\r+c 6\ rq f .
u) D&rra Eao}:edd 610 ,^D&Sgd;d ,ilsoi. '-l
Prcsent residential address of Consrnrction Workcr (-\L1 t

3 EdciFdib 6Ec,sFodFbr,d Ear$rrao AEd{il Effi. to$d d$rb i$$

4d rS+ iudxo o;Jrbo r

oqpoa
4d aa$''
rt
oilils
*tDdo
odrLoo
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Locadon
Narne and locatioas of thc workVprojects wlpro
ernployed and at crage wages
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Namq & Type of No, of Avg. daily
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tha Wtrk D6yB rYBges

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&eo;j ;:ja&,ea1r: io arb$dcc$ d, r$,no, AoA.foX*
uair:t silaa roar$dc 3!d) acsorur rX;on-Cgr*.
certificd tbat above informa$on is correci and I am persooally
liable f.or proserution and any other action, if abo,e

fAG\Y\\\ (C]REDAIi
{,szPlace:
CIu.or/Date: Narre & Signature of Enr
(CREDA