THE PUNJAB EMPLOYEES SOCIAL SECURITY INSTITUTION

CERTIFICATE OF CONTRIBUTIONS WAGES AND EMPLOYMENT

Name of

Secured Person______________________ Social

Security A
Number

Ticket Number/Works Number/khatta etc.______________________________________

I certify that the above named person has been (1) continuously employed be me

And paid contribution for at least 90/180 days during the last 6/12 months and the
number of days worked by HIM or HER in each of the last 6/12 months was as under :-

MONTH Number of Days MONTH Number of Days

1 1
2 2
3 3

( ii ) The last date of work was

( iii ) The rate of wages last paid to HIM or HER was :-

Rs. Per
Rupees

( iv ) I further certify that the above named person was in my employment

___________________( date of accident or of on set of occupational disease ).

( v ) A report of the accident on Form B-3

HAS NOT been submitted.

NO. of Employer

___________________ Employer’s Stamp

( Date )_________________( Signature )__________________

On behalf of Employer

WEST PAKISTAN EMPLOYEES SOCIAL SECURITY

INSTITUTION

CERTIFICATE OF FITNESS TO RESUME WORK