Professional Documents
Culture Documents
Kar Shops Commercial
Kar Shops Commercial
1 2 3 4 5 6
Sl.No Name Desgn(wkg./ Residential Tel: [O][R] Fax/E-
Nonwkg) Address mail
\\1 2 3 4 5 6
Sl.No Name Desgn(wkg./ Residential Tel: [O][R] Fax/E-
Nonwkg) Address mail
4 Nature of Business.
PART B
In case of renewal, the following information shall be furnished in addition to the
information in Part A
PART C
1 Original Registration Certificate No. :
The following changes have taken place in respect of information furnished in Part A
( necessary documents shall be enclosed )
Sl.No Sl.No in Present Description Description after change Reasons for change
Part A ( Previsous declaration)
I / We hereby certify that the information furnished under Part A, B and C of this
Combined Application Form, are complete and true to the best of my / our knowledge
and in case any information proved to be false, I/ We would be liable for legal
consequences thereof.
Name)………………………………………………………………..Son/Daughter of
Descritption Marks.
Place
Date. Signature of
employer.
FORM Q
[ See Rule 24(9A)]
APPOINTMENT ORDER
1. Name & Address of the
Establishment.
6. Father/Husband Name.
7. Date of Birth.
9. Designation.
Place.
Women
Total.
17. Particulars of Women Employees who are willing nto work during night shifts.
Place,
1. Establishment Telephone
Location Fax
Address e-mail
2. Registered office/ Head office
Location
Address
3. Name & residential address of the Employer or a person responsible for Conduct & control of Business
Name Designation Residential Address Telephone
Office
Residence
Mobile
e-mail
4. Name and Residential Address of the Manager/Authorized Signatory:
Name Designation Residential Address Telephone
Office
Residence
Mobil
e-mail
6. A) Particulars of Employment
No. of
No. of
persons on roll Total amount of
persons on
as on No. of days No. of Man days No. of man hours
Roll as on salary/wages paid
1-1-200 establishment worked during the worked including O.T.
31-12-200 including O.T. wages
(Year worked year during the year
(Year end and allowances (in Rs,)
commencement
date)
date)
Men
Women
Total
6. B) No. of employees whose employment is ceased:
No. of employees discharged/ dismissed/ No. of employees Amount of
Amount of
terminated/ retrenched/ resigned/ retired during suspended during subsistence
compensation paid
the year the year allowance paid
1 2 3 4
7. Particulars of Earned Leave with Wages
No. of employees No. of employees No. of employees paid
Category of Total no. of persons
eligible for earhed availed\Granted wages/salary in lieu of
employees employed
leave earned leave earned leave.
1 2 3 4 5
i) Men
ii)Women
8. Whether the following Welfare measures are provided?
1. Canteen
2. Creches
3. Shelters, Rest rooms and Lunch rooms
4. Transport facility
9. Maternity Benefit :
A) Particulars of Maternity Benefits:
1. Total No. of women workers who worked for a period of 160 days in the last 12 months
immediately preceding the date of delivery
2. No. of women workers discharged/dismissed in the last 12 months
3. No. of women workers for whom pre-natal confinement and post-natal confinement is
provided by the employer with free of cost.
4. No. of women workers died a. Before delivery b. After delivery
Total
Certified that the information furnished above to the best of my knowledge and belief, is correct.