Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697804376772.pdf (India)
Self-Certificate Regarding Employment (To be issued by Construction Labour) This is to certify that I (Name of Construction Worker)____________________________________________________S/o-D/o- W/o__________________________________________Address______________________________________ ___________________________________________________________________________________ am working as ___________________________(nature of work) which comes under the category of construction worker.
have I /At_____________________________________________________(Post) and at other sites worked more days than one last 90 in year with M/s.

Above certificate is being issued by me under Rule 266(3) of DBOCWW (Rule and Service conditions for Employment) Rules, 2002 and I am completely responsible for its genuine ness.
Date Signature Name: ___________________________________________________________________________ jkstxkj laca/kh Áek.k&i= ¼ स्वयं }kjk½ मैं ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ (नाम) iq=@iq=h@iRuh ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- irk ---------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- यह सत्यापित करता ह ूँ पक मैं --------------------------------------------------------------------------------- ---------------(कायय ) का काम करता ह ूँ जोपक निर्ायण कायय के अंतर्गत आता है मैंने fiNys ,d o’kZ esa 90 ¼uCcs½ fnuks a ls vf/kd lfUuekZ.k Jfed ds :i esa ___________________________________________________________________________ __________ (कॉन्ट्रैक्टर का नाम , पता ) व अन्ट्य जगहों पर dke fd;k gSaA उपरोक्त सत्यापि धारा 266 (3) डी बी ओ सी डब्ल्यू डब्ल्यु नियर्, 2002 के अंतर्यत र्ैं दे रहा ह सत्यता के निए पूरी तरह से र्ैं निम्र्ेदार ह ूँ l ूँ और इसकी fnukad gLrk{kj % uke