Specimen form of the Register regarding Maternity benefit admissible to

Contractor’s Labourer in Cochin Shipyard Limited

Name of Work:
Name of the Contractor:
1.	Name of the woman and her husband’s name	:
2.	Designation	:
3.	Date of appointment	:
4.	Rates with months and year in which she is employed	:
5.	Date of discharge / dismissal if any.	:
6.	Date of production of Certificate in respect of pregnancy.	:
7.	Date of which the woman informs about the expected delivery.	:
8.	Date of delivery / miscarriage / death	:
9.	Date of production of Certificate in respect of delivery / miscarriage.	:
10.	Date with the amount of maternity / death benefit paid in advance after expected delivery.	:
11.	Date with the amount of subsequent payment of maternity benefit.	:
12.	Name of the person nominated by the woman to receive the payment of the maternity benefit after her death.	:
13.	If woman dies, the date of her death, the name of person to whom maternity / benefit amount was paid, the date of payment	:
14.	Signature of the Contractor authenticating entries in the Register.	:
15.	Remarks column for the use of Inspecting Officer.	: