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Form
Form
Form
XXV of (Rules 82(2) of the Contract Labour (Regulation & Abolition) Karnataka Rules, 1974
III (Rule 22(4)) Karnataka Minimum Wages Rules, 1958
XX (Rule 20(1)) Karnataka Payment of Wages Rules, 1963
L (Rule 16) Karnataka Maternity Benefits Rules, 1963
a)
Establishment
b)
Name and Residential Address of the Employer or a person Responsible for Conduct and Control of the Business :
Name
Designation
Residential Address
Telephone
1
2
3
4
Location
Address
Telephone
(o)
( R)
4
Telephone
4
(o)
( R)
(o)
( R)
5
Category of Employees
i)
Men
NA
NA
NA
ii)
Women
NA
NA
NA
i)
Canteen
ii)
Creches
iii)
iv)
Transport Facility
Total number of Women workers who worked for a period of 160 days in the last 12 months immediately preceding the date of delivery
Number of Women workers for whom pre-natal confinement and post-natal confinement is provided by the employer with free of cost
4
Number of women workers died
Before Delivery
After Delivery
Miscarriage
NA
NA
10
Confinement
NA
NA
Miscarriage
NA
NA
Illness
NA
NA
Medical Bonus
NA
NA
i)
Fines
NA
ii)
Damages / Loss
NA
iii)
Breach of Contract
NA
iv)
Others
NA
Total
NA
11
Contract Labour
Period of Contract
From / To
Nature of Work
i)
NA
NA
NA
NA
ii)
NA
NA
NA
NA
iii)
NA
NA
NA
NA
Certifited that the information furnished above is, to the best of my knowledge and belief, is correct.
Datedxx-xx-xxxx
Place
FORM U
Fax
Mobile
5
E-mail
6
Mobile
5
E-mail
6
Amount of
subsistence allowance
paid
NA
NA
NA
NA
NA
No
No
No
No
NA
nths
NA
NA
NA
NA
Leave sanctioned
Leave rejected
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
No. of
Mandays
Worked
NA
NA
NA
NA
NA
NA