FORM24A

(See Rule 115 in The Maharashtra Factories Rules 1963)

Notice of Dangerous Occurrence

Factory Information /

UTN /

Factory Status /

Factory Code /
1
Name of the factory /

Address of the factory /

State

City

PIN code

Phone No. /

Fax No. /

General Information /

2 Name of occupier /

Address of occupier /

3 Name of the manager /

Address of the manager /

4 Type of factory /

5 Branch or exact place where the dangerous

occurrence took place

6 Date & hour of occurrence

7 Nature of dangerous occurrence (State exactly

what happened) /

I certify that to the best of my knowledge and belief, the above particulars are correct in every respect.

Place: Signature of the Occupier/Manager

Date of dispatch of Report: