Govt. of National Capital Territory of Delhi, 5 Sham Nath Marg, Delhi.

District Dated

1 Name of the Establishment

2 Address

3 Nature of activity of Business

Name of proprietor / partner /

i.
Directors/occupiers
4
Whether Registered under Factories
ii. Yes No
Act, 1948

Daily Piece
5 No. of workmen/employees employed Regular
Wages Rate

i. No of Male

ii. No .of Female

iii. Total

6 Category of employees/workmen & their nos.

i. Unskilled

ii. Semi-skilled

iii. Skilled

vi. Supervisor

v. Managerial

7 Whether contractual workmen employed Yes No

i. No. of Contract Labour employed

ii. Name & address of the contractor

Whether Licence obtained under

iii. Contract Labour (Regulation & Yes No
Abolition) Act, 1970.

Whether principal employer has

iv. obtained registration certificate under Yes No
Contract Labour (Regulation &
 District Dated

Abolition) Act, 1970.

Whether following statutory records are

8
maintained.

i. Appointment letter issued Yes No

ii. Wages Register Yes No

iii. Attendance Register/card, Yes No

iv. Wage slip Yes No

v. O.T. Register Yes No

vi. Leave Card Yes No

vii. Fine Register Yes No

Whether Leave book/leave card

viii. Yes No
being maintained

Coverage of employees under ESIC 1948. if

9 applicable, If employing more than 10 Yes No
workers.

Coverage of employees under EPF & MPA

10 1952, if applicable. If employing more than Yes No
20 workers

Whether Register A. B. C under Payment of

11 Yes No
Bonus Act, 1965 is maintained

Whether Register maintained by the occupier

12 Yes No
u/s 11 of Child Labour (R&A) Act, 1986.

Whether abstract of Minimum Wages Act.

13 Yes No
1948, displayed

Potential No. of workers assessed on the

14 basis of machines installed, area of the Yes No
factory, packaging needs and no. of shifts.

15 Remarks, if any.

Name & Sign of Inspector & Sign of Occupier /Proprietor/partner/Director/

Manager/Employees