Statement under section 7(6) [See Rule 7]

õÅÛ¾Û 7(6) Ðéü¥øǶÛä× ÜÈÛÈÛÁõ¨Û ¸ÛªÛõ [›ä÷…Ûé õÛ¶Ûä¶Û 7]

FORM “ D ”
¶Û¾Ûä¶ÛÛé “ ¦øà ”

1. Name of the establishment

:
ÍÛ×ͬÛÛ¶Ûä× ›÷Ûé ¶ÛÛ¾Û ÐüÛé¿Û ©ÛÛé
2. Postal address and situation of the
establishment :
ÍÛ×ͬÛÛ¶Ûà ¤ø¸ÛÛÅÛ¶Ûä× ÍÛÁõ¶ÛÛ¾Ûä× …¶Ûé ͬÛǶÛà ÜÈÛ•Û©Û
3. Situation of office, storeroom, godown,
warehouse, or workplace if any, attached to a
shop but situated in premises different from
those of the shop. :
−äùõÛ¶Û ÍÛÛ¬Ûé ›÷Ûé¦øÛ¿ÛéÅÛ ¸Û¨Û −äùõÛ¶Û¶ÛÛ Í¬ÛǬÛà …ÅÛ•Û Í¬ÛÇé
…ÛÈÛéÅÛ õ˜ÛéÁõà-ͤøÛéÁõÄõ¾Û-•ÛÛé−ùÛ¾Û-ÈÛ”ÛÛÁõ éõ õÛ¾Û¶Ûä× Í¬ÛÇ
ÐüÛé¿Û ©ÛÛé ©Ûé ͬÛÇ …וÛé¶Ûà ÜÈÛ•Û©Û.
4. Name of the employer
:
¾ÛÛÜÅې¶Ûä× ¶ÛÛ¾Û
5. Residential address of the employer
:
¾ÛÛÜÅېõ¶ÛÛ ÁõÐéü¥øÛ¨Û¶ÛÛ Í¬ÛǶÛä× ÍÛÁõ¶ÛÛ¾Ûä×.
6. Name of the Manager if any, and his
residential address. :
›÷Ûé ÐüÛé¿Û ©ÛÛé È¿ÛÈÛͬÛ۸ېõ¶Ûä× ¶ÛÛ¾Û …¶Ûé ÁõÐéü¥øÛ¨Û¶Ûä× ÍÛÁõ¶ÛÛ¾Ûä×.
7. Category of the establishment i.e. whether
shop, commercial establishment, residential
hotel, restaurant, eating house, theatre or
other place of public amusement or
entertainment. :
ÍÛ×ͬÛÛ¶ÛÛé ¸ÛóõÛÁõ …é¤øÅÛé éõ −äùõÛ¶Û, ÈÛé¸ÛÛÁõà ÍÛ×ͬÛÛ, ÁõÐéüÈÛÛ¶Ûà
ÍÛ•ÛÈÛ¦ø µÛÁõÛÈÛ©Ûà ÐüÛé¤øÅÛ, ÁéõͤøÛéÁõÛ×, ½ÛÛé›÷¶ÛÛÅÛ¿Û, ¬Ûà…é¤øÁõ
…¬ÛÈÛÛ …Û¶Û×−ù ¸Ûó¾ÛÛé−ù éõ ¾Û¶ÛÛéÁ×õ›÷¶Û ¾ÛÛ¤éø¶Ûä× …¶¿Û ›÷ÛÐéüÁõ
ͬÛÇ ™öé éõ éõ¾Û?
8. Nature of business
:
õ۾ېõÛ›÷¶ÛÛé ¸ÛóõÛÁõ
9. Date of commencement of business
:
µÛ×µÛÛé ÉÛÄõ õ¿ÛÛÙ¶Ûà ©ÛÛÁõà”Û
10. Name of members of business family
employed in the establishment
Adult men ________
Adult women ______
Young persons _______
Total _______
:
ÍÛ×ͬÛÛ ¾ÛÛÜÅېõ¶ÛÛ ¸ÛÛé©ÛÛ¶ÛÛ äõ¤ä×ø¼Ûà›÷¶ÛÛé ÍÛ×ͬÛÛ¾ÛÛ× ¶ÛÛéõÁõà…é
ÁõÛ”ÛÈÛÛ¾ÛÛ× …ÛÈ¿ÛÛ ÐüÛé¿Û ©ÛÛé ©Ûé¾Û¶ÛÛ ¶ÛÛ¾ÛÛé
¸Ûä”©Û ÈÛ¿Û¶ÛÛ ¸ÛäÂúÌÛ ________
¸Ûä”©Û ÈÛ¿Û¶Ûà ͪÛà…Ûé _______
¶ÛÛ¶Ûà ÈÛ¿Û¶ÛÛ× ________
äõÅÛ _________
11. Name of other persons occupying position of
Management or Employees engaged in
confidential capacity (indicate sex and age in
case of young persons).
:
È¿ÛÈÛͬÛÛ ©Ûת۾ÛÛ× ÐüÛé°ùÛé µÛÁõÛÈÛ©Ûà …¶¿Û È¿Û܏©Û …¬ÛÈÛÛ
ÜÈÛÊÈÛÛÍÛ¸ÛÛªÛ È¿Û܏©Û…Ûé¶ÛÛ ©ÛÁõàéõ õÛ¾Û¾ÛÛ× Áõ”ÛÛ¿ÛéÅÛà
È¿Û܏©Û…Ûé¶ÛÛ ¶ÛÛ¾Û (¶ÛÛ¶Ûà ÈÛ¿Û¶ÛÛ È¿Û܏©Û…Ûé¶Ûà ¼ÛÛ¼Û©Û¾ÛÛ×
›÷ÛÜ©Û …¶Ûé ÈÛ¿Û −ùÉÛÛÙÈÛÈÛà)
12. Total number of employees:
Adult men _______
Adult women ______
Young persons ______
Total ______
:
¶ÛÛéõÁõà¿ÛÛ©ÛÛé¶Ûà äõÅÛ ÍÛ×”¿ÛÛ:
¸Ûä”©Û ÈÛ¿Û¶ÛÛ ¸ÛäÂúÌÛ _______
¸Ûä”©Û ÈÛ¿Û¶Ûà ͪÛà…Ûé ______
¶ÛÛ¶Ûà ÈÛ¿Û¶ÛÛ× _______
äõÅÛ _________
13. Registration No. and Date
:
¶ÛÛêµÛ¨Ûà ¶Û×¼ÛÁõ …¶Ûé ©ÛÛÁõà”Û
14. Date of last renewal
:
™öéÅÅÛà ©ÛÛœ÷ õÁõÛÈ¿ÛÛ¶Ûà ©ÛÛÁõà”Û
Date Signature of the Employer
©ÛÛÁõà”Û ¾ÛÛÜÅېõ¶Ûà ÍÛÐüà
Note:-
1. This statement shall be sent to the Inspector of the local area concerned with such face
as are prescribed schedule.
2. Item 3 should be filled only when the office, storeroom, etc. is not separately
registered under the Act, in respect of such office, storeroom, etc. particulars are
required under 10, 11 & 12 should be given separately in this statement.
3. The Original Certificate in C shall be enclosed.
4. If the number of employers is more than one, then names and residential address of all
employers shall be given in items 4 & 5 respectively.
1. …¶ÛäÍÛæ˜Ûà [2] ¾ÛÛ× ¥øÁõÛÈÛéÅÛà ºõà ÍÛÛ¬Ûé ÅÛÛ•Û©ÛÛ ÈÛÇ•Û©ÛÛ ÜÈÛÍ©ÛÛÁõ¶ÛÛ Ü¶ÛÜÁõ“ېõ¶Ûé ÜÈÛÈÛÁõ¨Û ¸ÛªÛ ¾ÛÛéõÅÛÈÛä×.
2. õ˜ÛéÁõà, ͤøÛéÁõÄõ¾Û ÜÈÛ•ÛéÁéõ¶Ûà …Û Ü¶Û¿Û¾Û¶Ûà Ðéü¥øÇ …ÅÛ•Û Áõà©Ûé ¶ÛÛêµÛ¨Ûà ¶Û õÁõÛ† ÐüÛé¿Û ©¿ÛÛÁéõ ¼ÛÛ¼Û©Û 3 ½ÛÁõÈÛà. …Û
õ˜ÛéÁõà¾ÛÛ× Í¤øÛéÁõÄõ¾Û ÜÈÛ•ÛéÁéõ …וÛé ¼ÛÛ¼Û©Û 10, 11 …¶Ûé 12 Ðéü¥øÇ …Û¸ÛÈÛÛ¶Ûà ¬Û©Ûà ÜÈÛ•Û©ÛÛé …Û ÜÈÛÈÛÁõ¨Û ¸ÛªÛõ¾ÛÛ×
…ÅÛ•Û …Û¸ÛÈÛà.
3. ¶Û¾Ûä¶ÛÛé “ ÍÛà ” ¾Ûä›÷¼Û¶Ûä× ¸Ûó¾ÛÛ¨Û¸ÛªÛ ÍÛÛ¬Ûé ¼Ûà¦øÈÛä×.
4. ›÷Ûé ¾ÛÛÜÅېõÛé¶Ûà ÍÛ×”¿ÛÛ …éõ¬Ûà ÈÛµÛÛÁéõ ÐüÛé¿Û ©ÛÛé ¾ÛÛÜÅېõÛé¶ÛÛ ¶ÛÛ¾ÛÛé …¶Ûé ÍÛÁõ¶ÛÛ¾ÛÛ …¶Ûä. ¶Û×.4 …¶Ûé ¸Û ¾ÛÛ× −ùÉÛÛÙÈÛÈÛÛ.
›ä÷…Ûé õÛéÅÛ¾Û 18 (1)
¸ÛóÜ©Û,
¼ÛÛé¾¼Ûé ÉÛÛ鸡ö …鶦ø …éͤøÛ¼ÅÛàÉÛ¾Û鶤ø 1948 …¶ÈÛ¿Ûé¶ÛÛ †¶Í¸Û鏤øÁõ
1. ¾ÛÛÜÅېõ¶Ûä× ¶ÛÛ¾Û: ________________________________________________.
2. ÍÛ×ͬÛÛ¶Ûä× ¶ÛÛ¾Û ›÷Ûé ÐüÛé¿Û ©ÛÛé: ________________________________________________.
3. ÍÛ×ͬÛÛ¶Ûä× ¤ø¸ÛÛÅÛ¶Ûä× ÍÛÁõ¶ÛÛ¾Ûä×: ________________________________________________.
4. Áõœ÷ͤøÁõ ÍÛ¤øâºõàéõ¤ø ¶Û×¼ÛÁõ: ________________________________________________.
5. µÛ×µÛÛ¶ÛÛé ¸ÛóõÛÁõ: ________________________________________________.

…¾ÛÛé …¾ÛÛÁõà Š¸ÛÁõ ›÷¨ÛÛÈÛéÅÛà ÍÛ×ͬÛÛ / ¸Ûé§øà ˜ÛÛÅÛä ÍÛÛÅÛé ____________________ ¬Ûà ÉÛÄõ ¬Û©ÛÛ× ÈÛÌÛÙ¾ÛÛ× ©ÛÛÁõà”Û
____________ ¬Ûà ©ÛÛÁõà”Û ____________ ÍÛäµÛà −ùÁéõõ ______________ ÈÛÛÁõ¶ÛÛ ÁõÛé›÷ ¼Û×µÛ ÁõÛ”Ûà …¥øÈÛÛܦøõ
Áõ›÷Û ¸ÛÛÇàÉÛä× ©Ûé¶Ûà ¶ÛÛêµÛ ÅÛéÉÛÛéœ÷.

©ÛÛ. ____________ ¾ÛÛÐéü ____________ ÈÛÌÛÙ ____________ ¾ÛÛÜÅېõ / ¾Ûé¶Ûé›÷Áõ¶Ûà ÍÛÐüà