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FORM A Statement under Section 5(1)

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FORM A Statement under Section 5(1)

Statement under Section 5 (1)

(See rule 3)

Part I

1. Name of the establishment, if any. ........................................
2. Postal address of the establishment. ........................................
3. Full name of the occupier or the employer [including his father's name]1 ........................................
4. Full name of the Manager, if any [including his father's name]1 ........................................
5. Category of the establishment, i.e., whether a shop, commercial establishment, residential hotel, restaurant, eating house, theatre or other place of public amusement or entertainment. ........................................
6. Nature of business. ........................................

Part II

 7. Names of members of employer's family, working in the establishment (state separately the names of young persons, if any). ........................................
8. Names of other persons occupying position of management or employees engaged in confidential capacity. ........................................
9. Total number of employees (state separately the number of men, women and/or young persons, if any). Men
Women
Young Person
10. Date on which the establishment commenced its work.2 ........................................
11. I hereby declare that the details given above are correct to the best of my knowledge.3

Dated .............................................................

Note: This statement shall be sent to the Chief Inspector with such fees as are prescribed in Schedule I.

Signature of the occupier/employer ..........................................................

Received from ........................................Form A with Challan No........................................

Signature

1. Added vide Notification No. F 12 (17)/56/1 & L of 9.4.56.
2. Deleted vide Notification No. 12 (23)/55-I&L of 9.1.57 but added vide Notification No. F 20(31)/58I&L 2nd Sept. 1958.
3. Added vide the Chief Commissioner of Delhi Notification No. F. 20(40)/63. Labour dated 7.8.64.

LAST UPDATED DATE :- 18-07-2019

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