(Required All Fields)

1. Name of Establishment( in block letters)  

2. Address of Head Office( in block letters)  
 

3. Telephone Nos. Establishment   

                                 Head Office 

4. Nature of Business                   

5. Name of Employer or M.D          .

6. Employees including Head Office & Contractors' Employees

a) Earning not exceeding Rs. 10,000/- No. in Figures   

b) Earning over Rs.10,000/-                                        

7. Name of dependents of the employees for S.No. 6(a)

8. Break-up of S.No.6 (a)
         i) No. of Head office Employees                         

ii) No. of Employees other than Head Office

        a) Employed by the Establishment                     

        b) Employed by the Contractor, if any                 

9. Break-up of

                S.No.6 (a) according to Sex:                      

10. Total monthly wages paid to Employees

                 a) Earning not exceeding Rs.10,000/- p.m.  

                 b) Earnings over Rs.10,000/- p.m.              

11. Whether registered in (Reply in Yes or No.)

                                      i)  E.O.B.I.                         

                                      ii) Shop Act                       

12)Establishment functioning from                              

 Date