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FORM ‘A’ (See sub rule (1) of Rule 3) 1. Name and address if the establishment M/s 2. Name and designation of the employer 3. Number of person employed 4. Maimum number of person!s employed on any Nos.  "ay during the pre#eding t$el%e months $ith date &. Numbers of employees #o%ered by the '#t . Nature of ndustry *. +hether seasonal ,. "ate of opening -. "etails of ead offi#e / ran#hes0 a) Name and address of the ead offi#e Number of employees 's abo%e  b) Name and address of other bran#hes in ndia0 1. N 2. 3. %erify that the information furnished abo%e is true to the best of my no$le4dge and belief. la#e0 For "ate0 Manager

AR Under Factory Act 1948

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FORM ‘A’

(See sub rule (1) of Rule 3)

1. Name and address if the establishment M/s

2. Name and designation of the employer

3. Number of person employed

4. Maimum number of person!s employed on any Nos.

  "ay during the pre#eding t$el%e months $ith date

&. Numbers of employees #o%ered by the '#t

. Nature of ndustry

*. +hether seasonal

,. "ate of opening

-. "etails of ead offi#e / ran#hes0

a) Name and address of the ead offi#e Number of employees

's abo%e

 b) Name and address of other bran#hes in ndia01. N

2.3.

%erify that the information furnished abo%e is true to the best of my no$le4dge and belief.

la#e0 For

"ate0 Manager

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NOTICE

NAME AND DESIGNATION OF THE AUTHORISED PERSON UNDER SECTION

4(1) OF THE PAYMENT OF GRATUITY RULES 1!"# TO RECEI$E NOTICES

UNDER THE ACT % RULES

1. N'M 56 7 '875RS" RS5N 0 MR.

2. "S9N'75N 56 7 '875RS"0

nds0"ated

 Noti#e oard

7he abour 5ffi#er:

7he abour nspe#tor:

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FACTORIES ACT 1!4&

6orm 34 (Re%ised);res#ribed under Rule 12(a)<

ANNUAL RETURN

6or the year ending 31st "e#ember ========== 

1. Registration number of 6a#tory 02. Name of 6a#tory 0 M/s3. Name of 5##upier 0 Mr.

4. Name of the Manager 0 Mr.

&. "istri#t 0. 6ull ostage 'ddress of 6a#tory 0

*. Nature of ndustry 0

 N8MR 56 +5R>R 'N" 'R7?8'RS 56 M5@MN7

,. No. of days $ored in the year 0

-. No. of Man "ays $ored during thea) Men 0

 b) +omen 0

#) ?hildren 0

1A. '%erage number of $orers employed 0

(See eplanatory note)

a) 'dults (i) Men

(ii) +omen

 b) 'doles#ent (i) Male(ii) 6emale

#) ?hildren (i) Male

(ii) 6emale

11. 7otal No. of Man hours $ored in#luding o%er time 0

a) Men 0 b) +omen 0

#) ?hildren 0

12. '%erage number of hours $ored per $ee 0(See eplanatory note)

a) Men 0 b) +omen 0

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13. (a) "oes the fa#tory #arry out pro#ess or operations

  "e#lared as dangerous under se#tion ,* (see rule 11)

  (b) if so: gi%e the follo$ing information

 Name of the dangerous pro#ess of operations '%erage No. of persons employed daily in ea#h of?arried on the pro#esses or operations gi%en in #ol 1

1 2

(i)

(ii)(iii)

LEA$E 'ITH 'AGES

14. 7otal number of $orers employed during the year0a) Men

 b) +omen

#) ?hildren

1&. Number of $orers $ho $ere entitled to annual

ea%e $ith $ages during the year a) Men

 b) +omen

#) ?hildren

1. Number of $orers $ho $ere granted lea%e during the year 

a) Men

 b) +omen#) ?hildren

1*. a) Number of $orers $ho $ere dis#harged: or "ismissed from the ser%i#es: or Buit employment:

5r $ere superannuated: or $ho died $hile

Ser%i#e during the year.

 b) Number of su#h $orers in respe#t of $hom

$ages in lieu of lea%e $ere paid.

SAFETY OFFICERS

1,. a) Number of Safety 5ffi#ers reBuired to be'ppointed as per notifi#ation under

Se#tion 4AC

  b) Number of Safety 5ffi#ers appointed

AMYLANCE ROOM

1-. s there an ambulan#e room pro%ided in the6a#tory as reBuired under Se#tion 4&D

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CANTEEN

2A. a) s there a #anteen pro%ided in the fa#tory

reBuired under se#tion 4D

 b) s the #anteen pro%ided managedD

  i) "epartmentally: or   ii) 7hrough a ?ontra#torD

SHELTERS OR REST ROOMS AND LUNCH ROOMS21. a) 're there adeBuate E suitable shelters or rest

Rooms pro%ided in the fa#tory as reBuired under 

Se#tion 4*D

 b) 're there adeBuate and suitable mu#h rooms

ro%ided in the fa#tory as reBuired under 

Se#tion 4*D

CRECHES

22. s there a #rF#he pro%ided in the fa#tory as

ReBuired under se#tion 4,D

'ELFARE OFFICER 

23. a) Number of +elfare 5ffi#ers reBuired to be'ppointed under se#tion 4-D

 b) Number of +elfare 5ffi#ers appointed

ACCIDENTS

24. a) 7otal Number of a##idents (see eplanatory note)i) 6etal

ii) NonC6etal

 b) '##ident in $hi#h $orers returned to $or "uring the year to $hi#h this returns relate.

i) '##idents ($orers inGured) o##urring during7he pre%ious year in $hi#h inGured $ors

Returned to $or during the year to $hi#h this

Return relates.

aa) Number of '##idents

 bb) Man "ays lost due to '##idents

#) '##idents ($orers inGured) o##urring during the

re%ious year in $hi#h inGured $orers did not

Return to $or during the year to $hi#h this return relate toaa) Number of '##idents

 bb) Man "ays lost due to '##idents

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SUGGESTION SCHEME

2&. a) s a suggestion s#heme in operation in the fa#toryD

 b) f so: the number of suggestions

i) Re#ei%ed during the year  ii) '##epted during the year 

d) 'mount a$arded in #ash priHes during the year i) 7otal amount a$ardedii) Ialue of maimum #ash priHes a$arded

iii) Ialue of minimum #ash priHes a$arded

?ertified that the information furnished abo%e is to the best of my no$ledge and belief: #orre#t.

Sgna*+re o, *-e Manager

Da*e........./

planatory Note0 C

1. 7he a%erage number of $orers employed daily should be #al#ulated by di%iding the aggregate numof attendan#e on $oring days (that is: man days $ored) by the number of $oring days in the yea

re#oning attendan#e: attendan#e by temporary as $ell as permanent employed should be #ounted

all employees should be in#luded: $hether they are employed dire#tly or under #ontra#tors. 'ttendaon separate shifts (e.g. night and day shifts) should be #ounted separately. "ays on $hi#h the fa#t

$as #losed for $hate%er #ause and days on $hi#h the manufa#turing pro#esses $ere not #arried

should not be treated as $oring days. artial attendan#e for less than half a shift on a $oring

should be ignored: $hile attendan#e for half a shift or more or su#h day should be treated as attendan#e.

2. 6or seasonal fa#tories: the a%erage number of $orers employed during the $oring season and season should be gi%en separately. Similarly the number of days $ored and a%erage number of m

hours $ored per $ee during the $oring and offCseason should be gi%en separately.

3. 7he a%erage number of hours $ored per $ee means the total a#tual hours $ored by all $or

during the year e#luding the rest inter%als but in#luding o%ertime $or: di%ided by the produ#t of t

number of $orers employed in the fa#tory during the year and &2. n the #ase the fa#tory has $ored for the $hole year: the number of $ees during $hi#h the fa#tory $ored should be use

 pla#e of the figure&2.

4. %ery person illed or inGured should be treated as one separate a##ident. f in one o##urren#e persons $ere inGured or illed: should be #ounted si a##idents.

&. n item 24(a): the number of a##idents: $hi#h too pla#e during the year: should be gi%en. n #ase nfatal a##idents only those a##idents: $hi#h pre%ented $orers from $oring for 4, hours or m

should be indi#ated.

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FORM NO/ III

Ann+a0 Re*+rn ,or *-e ear #22&

res#ribed under se#tion 1,() of the Minimum +ages '#t: 1-4, abd Rule 21 (4C') of the .. Minimum

+ages Rules: 1-&-

 Note0 nformation may be gi%en only for those #ategories of $orers in respe#t of $hom minimum $ages h

 been fied under the minimum $ages a#t: 1-4,.

1. Name of stablishment $ith full postal address0

2. No. of days $ored during the year0

'dults ?hildren3. No. of Man days $ored during the year ========= ========  

(7otal 'ttenden#e)

4. '%erage No. of persons employed daily during7he year ========= =========  

&. 7otal +ages aid Rs.=============  

. ?ash Ialue of +ages aid in >ind

*. "edu#tions made on a##ount of

6ine "amage or oss rea#h of ?ontra#t

 No. of ?ases 'mount No. of ?ases 'mount No. of ?ases 'mount

,. alan#e of the fine fund at the beginning of the year ================== 

-. "isbursement from the fine fund0 C

urpose 'mount Spent

a) ============================= ============================== 

 b) ============================= =============================== 

#) ============================= =============================== 

d) ============================= =============================== 

1A. alan#e of fine fund at the end of the year0 ============================= 

Sgna*+re o, *-e Manager

"ate JJJJJJJJ

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FORM I$

ANNUAL RETURNS UNDER THE PAYMENT OF 'AGES ACT 1!3

'AGES AND DEDUCTION FROM 'AGES5

RETURN FOR THE YEAR ENDING 31ST DECEMER #22&

1. a) Name of the fa#tory or establishment and postal address

 b) ?ode No.

#) ndustry

2. Number of days $ored during the year03. a) No. of Man days $ored during the year0

 b) '%erage daily No. of persons employed during the year0

ersons re#ei%ing ersons re#ei%ing Rs. 1AAA andess than Rs. 1AAA more but less than Rs. 1AAAA

'dults

?hildren

a) 9ross amount paid as remuneration to persons getting less than Rs. 1AAA in#luding dedu#tions und

se#tion * (2) JJJJJJJJ.. of $hi#h the amount due to profit sharing bonus is

JJJJJJJJJ.. and that due to money %alue of #on#ession is JJJJJJJJJJJJ b) 9ross amount paid as remuneration to persons getting Rs. 1AAA and more but less than 1AAAA

in#luding dedu#tions under se#tion * (2) JJJJJJ of $hi#h the amount due to profit sharing

 bonus is JJJJJJJ. 'nd that due to money %alue of #on#ession is JJJJJJJJJ..<

4. To*a0 6age7 8a9 n:0+9ng 9e9+:*on7 +n9er 7e:*on " (#) on *-e ,o00o6ng a::o+n*  0C

ersons re#ei%ing less ersons re#ei%ing Rs. 1AAA an

7han Rs. 1AAA more but less than Rs. 1AAAA

a) asi# $ages in#luding o%er time

+ages and nonCprofit sharing

onus b) "earness and other allo$an#e

n #ash

#) 'rrears of pay in respe#t of pre%ious

@ear paid and during the year.

;/ N+<=er o, :a7e7 an9 a<o+n* rea0>e9 a7? @

ersons re#ei%ing less ersons re#ei%ing Rs. 1AAA and

7han Rs. 1AAA more but less than Rs. 1AAAA

  No. of   ?ases  'mount No. of ?ases 'mount

a) 6ines

 b) "edu#tion for "amages or oss#) "edu#tion for rea#h of ?ontra#t

. "isbursement 6rom 6ines fund0 urpose 'mounta)

 b)

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*. alan#e of fines fund in hand at the end of the year Rs. JJJJJJJJJ.

Signature JJJJJJJ.

"esignation JJJJJJ.

• 7his is the aggregate number of attendan#e during the year. 7he a%erage daily number person

employed during the year is obtained by di%iding the aggregate number of attendan#e during

year by the number of $oring days.

• Money %alue of #on#essions should be obtained by taing differen#e of the #ost pri#e paid by

employer and the a#tual pri#e paid by the employees for supplier of essential #ommodities gi%

free or at #on#essional rates.

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MATERNITY ENEFIT ACT 1!1

FORM ‘N’

(See rule 1)

(M'7RN7@ N67 R8S: 1-*3)

"etails of payment made during the year ending 31st "e#ember 2AA,

M/S

 Name of person to $hom paid ============= 'mount paid ============= 

1. "ate of payment =============== 

2. +oman mployee ===============  

3. Nominee of $oman ===============  

4. egal representati%e of $oman ===============  

&. 'mount for the period pre#eding date of epe#ted deli%ery =============== 

. 'mount of the subseBuent period ===============  

*. 8nder se#tion , of the '#t =============== 

,. 8nder se#tion - of the '#t ===============  

-. 8nder se#tion 1A of the '#t ===============  

1A. Number of the $oman $orers $ho abs#onded after re#ei%ing the first installment of

maternity benefits ===============  

11. ?ases $here #laims $ere #ontested in a #ourt of la$ ===============  

12. Result of su#h #ases ===============  

13. Remars ===============  

SIGNATURE OF THE EMPLOYER 

"ate ============= 

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MATERNITY ENEFIT ACT 1!1

FORM LB

(See Rule 1)

ANNUAL RETURN FOR THE YEAR ENDING 31ST DECEMER #22&

1 Name of the stablishment M/S

2 'ddress of the establishment: .5. "istri#t

3 "ate of opening the establishment

4 "ate of #losing: if #losed

& ostal address of the establishment

Name of the mployer: postal address of themployer 

 

* Name of Managing 'gent: if any: ostal

'ddress of Managing 'gent

 

, Name of 'gent or Representati%e of employer:

ostal address of Representati%e of mployer 

 

- Name of Manager: ostal address of Manager

1A (a) Name of Medi#al 5ffi#er: if any atta#hed tothe establishmentD

(b) Kualifi#ation of medi#al 5ffi#er atta#hed to

the establishment

(#) s he resident at the establishmentD(d) f a part time employee: ho$ often does he

 pay %isit to the establishmentD

 

11 (a) s there any hospital atta#hed to the

establishmentD

(b) f so: ho$ manyu beds are pro%ided for$omen employeesD

(#) s there a lady "o#torD

(d) f so: $hat are her Bualifi#ationsD

(e) s there a Bualified Mid$ifeD(f) as any ?re#h been ro%idedD

 

"'70 C

SIGNATURE OF THE EMPLOYER 

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For< 3;

HALF YEARLY RETURN

6or the eriod ending 3Ath Lune =========== 

 Name of 6a#tory 0 M/s

 Name of 5##upier 0 Mr.

 Name of the Manager 0 Mr.

1. "istri#t 0

2. 6ull ostage 'ddress of 6a#tory 03. Nature of ndustry 0

4. '%erage No. of mployees $ored 0

Men 0+omen 0

'dults

Men ================== +omen =============== 

?hildernMen ================== 

+omen =============== 

&. 7otal Number of ours $ored at the end of -11A4 hrs

31st "e# 2AA, during the alf @ear ======= "ays

Signature of 5##upier  Sgna*+re o, Manager

• 7he a%erage number of $orers employed daily should be #al#ulated by di%iding the aggrega

number of attendan#e on $oring days (that is man days $ored) by the number of $oring d

in the last si months. n re#oning attendan#e: attendan#e by temporary as $ell as permanentemployed should be #ounted and all employees should be in#luded: $hether they are employe

dire#tly or under #ontra#tors. 'ttendan#e on separate shifts (e.g. night and day shifts) should b

#ounted separately. "ays on $hi#h the fa#tory $as #losed for $hate%er #ause and days on $h

the manufa#turing pro#esses $ere not #arried on should not be treated as $oring days.• artial attendan#e for less than half a shift on a $oring day should be ignored: $hile attenda

for half a shift or more su#h day should be treated as full attendan#e

?ertified that the information furnished abo%e is to the best of my no$ledge and belief: #orre#t.

"ate JJJJJJJJJJ.. Sgna*+re o, *-e Manager

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'ORMEN’S COMPENSATION

Return relating to period from LanC2AA, to 31st "e#C2AA,

State 0

"istri#t 0

7o$n or Iillage 0

ost 5ffi#e 0

 Name of stablishment 0

 Name of +or 0

'%erage Numbers mployed er day 0 ==================================== 

'dults (Men) 0

Minors (+omen) 0

'##idents 5##upational "iseases

 Number of #ases of inGuries inrespe#t of $hi#h final

#ompensation has been paid

during the year 

'mount of #ompensation paid Number of #ases of diseases inrespe#t of $hi#h final

#ompensation has been paid

during the year 

'mount of #ompensation pa

   "  e  a   t   h

   3  e  r  m  a  n  e  n   t

   "   i  s  a   b   l  e  m  e  n   t

   7  e  m  p  o  r  a  r  y

   "   i  s  a   b   l  e  m  e  n   t

   "  e  a   t   h

   3  e  r  m  a  n  e  n   t

   "   i  s  a   b   l  e  m  e  n   t

   7  e  m  p  o  r  a  r  y

   "   i  s  a   b   l  e  m  e  n   t

   "  e  a   t   h

   3  e  r  m  a  n  e  n   t

   "   i  s  a   b   l  e  m  e  n   t

   7  e  m  p  o  r  a  r  y

   "   i  s  a   b   l  e  m  e  n   t

   "  e  a   t   h

   3  e  r  m  a  n  e  n   t

   "   i  s  a   b   l  e  m  e  n   t

   7  e  m  p  o  r  a  r  y

   '   d  u   l   t

   M   i  n  o  r  s

"ate0JJJJJJJJJ SignatureJJJJJJJJJJJJ

"esignationJJJJJJJJJJJ

 Note4s0 C1. n #ase $here more establishment than one are o$ned by the same employer: a separate return should be furnished for

establishment. +hen in any establishment the $ormen employed fall in t$o or more of the distri#t #ategories to $hi#h the r

relates: e.g. in the #ase of a tea estate #ategories ' and (%) a separate sheet should be used for the statisti#s of ea#h #ategory

2. nter the #lass of establishment a##ording to the pro#ess or produ#t: e.g. #otton $ea%ing and spinning fa#tory: #oal mine.3. n#lude all employees $hether permanent or temporary $ho $ould: in the #ase of a##idents be eligible for #ompensation u

the a#t and for $hom a return is reBuired to be furnished. Numbers employed should be sho$n e%en if there are no paymen

#ompensation to report.4. n#lude only those #ases in $hi#h the final payment of #ompensation $as made during the year. ' deposit $ith #ommiss

should be treated as a payment of the employer.

&. n#lude all #ompensation paid in respe#t of the #ases mentioned in footnote (4): $hether su#h #ompensation $as paid durin

year or pre%ious to its #ommen#ement. #lude all payments in #ases in $hi#h the final payment had not been made by the en

the year to $hi#h the return relates.. 5nly su#h disablement as last for more than se%en days should be sho$n ;Se#tion (4) ()(d) of the '#t<

*. +here the benefit a#tually allo$ed (e.g. hospital lea%e on full pay) is in e#ess of the #ompensation admissible under the a#t:

the amount of #ompensation so admissible should be entered in the return.,. IiH: anthra: lead poisoning: phosphorus poisoning: mer#ury poisoning: benHene poisoning: #hrome ul#eration and #ompre

air illness only.

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MATERNITY ENEFIR ACT 1!1

FORM ‘O’

(See rule 1)

(HIMACHAL PRADESH MATERNITY ENEFIT RULES 1!"3)

rose#ution during the year ending 31st "e#ember 2AA,

M/S

la#e of employment of 

the $omen employee

 Number of #ases instigated Number of #ases $hi#h

resulted in #on%i#tion

Remars

SIGNATURE OF EMPLOYER 

"ated0 ======================= 

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MATERNITY ENEFIT ACT 1!1

FORM MB

(See Rule 1)

EMPLOYMENT DISMISSAL PAYMENT OF ONUS ETC/ OF 'OMEN FOR THE YEAR ENDIN

ON 31ST DECEMER #22&

1 Name of ;the Mine or ?ir#us<

2 'ggregate number of $omen permanently or temporarily employed duringthe year 

 

3 Number of $omen $ho $ored for a period of not less than ;eighty days< in

the t$el%e months immediately pre#eding the date of deli%ery

 

4 Number of $omen $ho ga%e noti#e under se#tion

& Number of $omen $ho $ere granted permission to remain absent onre#eipt of noti#e of #onfinement

 

Number of #laims for maternity benefit paid

* Number of #laims for maternity benefit reGe#ted

, Number of #ases $here preCnatal: #onfinement and postCnatal #are $as pro%ided by the management free of #harge (se#tion ,)

 

- Number of #laims for medi#al bonus paid (se#tion ,)

1A Number of medi#al #laims for medi#al bonus reGe#ted.

11 Number of #ases in $hi#h lea%e for mis#arriage ;M7< $as granted.

12 Number of #ases in $hi#h lea%e for mis#arriage ;M7< $as applied for but

$as reGe#ted.a) Number of #ases in $hi#h lea%e for tube#tomy operation under

se#tion -' $as granted.

 b) Number of #ases in $hi#h lea%e for tube#tomy operation $asapplied for but $as reGe#ted.

 

13 Number of #ases in $hi#h additional lea%e for illness under se#tion 1A $asgranted

 

14 Number of #ases in $hi#h additional lea%e for illness under se#tion 1A $asapplied for but $as reGe#ted.

 

1& Number of $omen $ho died

a) efore deli%ery. b) 'fter deli%ery.

 

1 Number of #ases in $hi#h payment $as made to persons other than the$oman #on#erned

 

1* Number of $omen dis#harged or dismissed $hile $oring

1, Number of $omen depri%ed of maternity benefit and / or medi#al bonus

under pro%ision to sub se#tion (2) of se#tion 12

 

1- Number of #ases in $hi#h payment $as made on the order of the?ompetent 'uthority or nspe#tor   

2A Remars

 N.. 6ull parti#ulars of ea#h #ase and reasons for the a#tion taen under serials *: 1A: 12: 14: 1* and 1, should

gi%en in 'ppendi belo$0C

"'70 C

SIGNATURE OF THE EMPLOYER 

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FORM $B

;See Rule ,2(2)<

ANNUAL RETURNS OF PRINCIPAL EMPLOYER TO E SENT TO THE REGISTERING OFFICE

ENDING YEAR ON 31ST DECEMER #22&

1 6ull name and address of the rin#ipal mployer

2 Name of stablishment

(a) "istri#t(b) ostal 'ddress

(#) Nature of operations / industry / $or #arried on

 

3 6ull name of the Manager or person responsible for super%ision and #ontrol

of the establishment

 

4 No. of #ontra#tors $ho $ored in the establishment during the year (9i%e

details in 'nneure)

 

& Nature of $or / operation on $hi#h #ontra#t labour $as employed

7otal number of days during the year on $hi#h #ontra#t labour $as

employed

 

* 7otal number of days maydays $ored by #ontra#t labour during the year 

, Maimum No. of $ormen employed dire#tly on any day during the year 

- 7otal no. of days during the year on $hi#h dire#t labour $as employed

1A 7otal No. of maydays $ored by dire#tly employed $ormen

11 ?hange: if any: in the management of the establishment: its lo#ation or anyother parti#ulars furnished to the Registering 5ffi#er in the appli#ation for

Registration indi#ating also the date

la#e0 >umarhatti

"'70 C

PRINCIPAL EMPLOYER 

'NNO8R 75 65RM

 Name and address eriod of ?ontra#t Nature of Maimum No. of No. of

5f the ?ontra#tor 6rom CC to oCC +or No. of $orers days Monda

mployed by ea#h $ored

$ored?ontra#tor 

1 2 3 4 &

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FORM I$B

;See Rule ,2(1)<

RETURN TO E SENT Y THE CONTRACTOR TO THE LICENSING OFFICER 

HALF YEAR ENDING ON 

1 Name and address of ?ontra#tor

2 Name and address of stablishment

3 Name and 'ddress of rin#ipal mployer

4 "uration of ?ontra#t 6rom to

& No. of days during the half year on $hi#h  

a) the establishment of the prin#ipal employer had $ored b) the #ontra#tors establishment had $ored

Maimum number of #ontra#t labour employed on any day

during the half year0

Men

'o<en

C-09ern* i) "aily hours of $or and spread o%erP  

ii) (a) +hether $eely holidays obser%ed and on $hatday

(b) f so: $hether it $as paid forP 

  iii) Number of man hours of o%ertime $oredP 

, Number of mandays $ored byC

Men

'o<en

C-09ern

- 'mount of $ages paid

Men

'o<en

C-09ern

1A 'mount of dedu#tions from $ages: if anyC

Men

'o<en

C-09ern

11 +hether the follo$ing ha%e been pro%idedi) ?anteen

ii) Rest Rooms

iii) "rining $ater  

i%) ?re#hes%) 6irst 'id

  (if the ans$er is yes! state briefly standards pro%ided)

la#e0 >umarhatti

"'70 C

Sgna*+re o, Con*ra:*or

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FORM D5

See R+0e ;5

'nnual return bonus paid to employees for the a##ounting year ending on 31.A3.2AA,

1. Name of stablishment and its #omplete postal M7

2. Name of ndustry M7

3. Name of mployer   

4. 7otal Number of mployee  

&. Number of employees benefited by bonus payments

1 2 3 4 &

7otal amount

 payable as bonus

under se#tion 1Aor 1 of the

ayment of  

onus '#t: 1-&as the #as may be

Settlement if 

any: rea#hed

under se#tion1,(1) or 12(3)

of the

ndustrial"ispute '#t:

1-4* $ith

date

er#entage of 

onus

de#lared to be paid

7otal amount of 

 bonus a#tually

 paid

"ate on $hi#h

 payment made

+hether 

 bonus has

 been paid toall the

employees if 

not: reason for non payment

Rema

R7/ NIL &/33 R7/ Pa9 *o a00e0g=0e

e<80oee

N

 For

A+*-or7e9 Sgna*or

6or$arded to 0 7he abour 5ffi#er ?um ?ontrolling 'uthority under ayment of onus '#t: Solan

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Ref. "ate0

7o7he abour ?ommissioner ?umC

?hief nspe#tor of 6a#tories:

Shimla ima#hal radesh

Sub. Submission of 'nnual Return 2AA,

R/Sir:

lease find en#losed here$ith the follo$ing do#uments0

1. 'ppli#ation in pres#ribed formC34 (Re%ised)

2. +ormen!s ?ompensation3. 'ppli#ation form No.

4. 'ppli#ation form No. I

&. Maternity enefit '#t: 1-1 6orm Q. Maternity enefit '#t: 1-1 6orm QN

*. Maternity enefit '#t: 1-1 6orm Q5,. Maternity enefit '#t: 1-1 6orm QM

-. ayment of onus '#t: 1-& 6orm Q"1A. alf yearly Return 6orm 3&

11. rin#ipal mployer Return 6orm C 2&

>indly do the needful and oblige.

7haning you.

@ours 7ruly:For

A+*-or7e9 Sgna*or