Form 12 ( See rule 67, 68) REGISTER OF WORKERS EMPLOYED FOR WORK ON OR NEAR MACHINERY IN MOTION 1). Name of worker 2). Serial no as in the register of workers under section 62 3). Father's Name 4). Date of Birth 5). Department 6). Nature of work 7). Qualification or period of service on similar work 8). Date when tight fitting clothing was provided 9). Remarks I certify that above mentioned worker whose signature or left thumb impression is given below is a properly trained male adult worker who is competent to mount or slip belts, lubricate and other adjusting operations on the machinery installed in my factory while they are in motion. Signature of left hand thumb impression of worker Signature of Occupier / Manager
