1. | Name of the establishment, if any. | |
2. | Postal address of the establishment. | |
3. | Full name of the occupier or the employer including his father's name1. | |
4. | Full name of the Manager, if any including his father's name 1 | |
5. | Category of the establishment, i.e., whether a shop, commercial establishment, residential hotel, restaurant, eating house, theatre or other place of public amusement or entertainment. | |
6. | Nature of business. | |
PART II |
7. | Names of members of employer's family, working in the establishment (state separately the names of young persons, if any). | |
8. | Names of other persons occupying position of management or employees engaged in confidential capacity. | |
9. | Total number of employees (state separately the number of men, women and/or young persons, if any). | Men, Women, Young Persons |
10. | Date on which the establishment commenced its work2. | |
11. | I hereby declare that the details given above are correct to the best of my knowledge. | |
| Dated ………………… | |
Note: | This statement shall be sent to the Chief Inspector with such fees as are prescribed in Schedule I. | Signature of the occupier/employer |
Received from ……….. Form A with Challan No ………….… | Signature |
