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iii)
iv)
v)
vi)
Form
Form
Form
Form
1.
2.
:
Location
Address
Telephone
Fax
E-
mail
1) Factory
2) Registered Head Office
3.
Mobile
Telephone
E-mail
(O)
(R)
4.
Mobile
5.
Telephone
E-mail
Occupier
(O)
(R)
Manager
(O)
(R)
Employer
6.
7.
Parti
culars
of
produ
cts
manu
factur
ed/
servic
e
Rend
ered
:
Name of the Product/
services
i)
ii)
iii)
iv)
Annual installed
Capacity
Quantity
Manufactured
Percentage
Achieved
Value
v)
vi)
8.
If yes:
i)
ii)
ii)
iv)
9.
a) Particulars of Employment
No. of
Persons on
Roll as on
1.1.200. . .
No. of Persons
on Roll as on
31.12.200 . . .
:
:
:
:
YES/NO
YES/NO
YES/NO
YES/NO
Women
Total
i) Men
No. of Employees
No. of
No. of
Discharged,
Employee
Employees
Dismissed,
s Eligible
Availed/Grant
Terminated,
for
ed Earned
Retrenched, Resigned
Earned
Leave
or Retired during the
Leave
year
No. of
Employees
paid
Wages\Salary
in lieu of
Earned Leave
ii)
Women
11.
a)
Number of Officers
actually appointed
i)
YES/NO
(ii)
YES/NO
Departmentally/
Contractor
1
YES/NO
YES/NO
:
:
:
:
:
13.
2.
3.
No.
of
women
workers
Before Delivery
After Delivery
is
Item
No. of
Women
applied for
leave
Leave
sanctioned
Leave
rejected
Miscarriage
illness (additional Leave
under Sec. 10)
Maternity Benefit Paid
item
No. of
claims
received
:
No. of leaves
sanctioned
No. of
claims
rejected
Total benefit
paid in
Rupees
Confinement
Miscarriage
Illness
Medical
Bonus
14.
No. of Employees
involved
i)
Fines
ii)
Damages/Loss
iii)
Breach of
contract
iv) Others
Total:
15.
16.
Percentage of
bonus/ Ex-gratia
declared
Contract Labour
:
Total amount of
Bonus/ Ex-gratia
paid
Date of
Payment
Name and
Max. No. of
No. of
Period of
No. of
No. of
address of
Nature
contract workmen
man
contract
persons
days
of work
employed on any
days
the
From/to
employed
worked
day during the year
worked
contractors
i)
ii)
iii)
iv)
Total
17.
Signature
Employer/Occupier/Manager
Dated:
Place:
....................
Designation . . . . . . . . . . . . . . . . . . . . . . . .
of
Name . . . . . . . . . .