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[FORM’A’] [See Rules 3(1), 3-A and 5] Combined Application ...

[ form A ][See Rules 3(1), 3-A and 5] Combined Application for Registration/Renewal/Any change under Karnataka Shops and CommercialEstablishments Act, 1961 and Rules there underPART A1 Name of the establishment and : Fax: E-mail1 AName of the Head Office, if any withpostal address:Tel: Fax: E-mail2 Details of the Proprietor/ Managing Partner/ Director(In case of partnership or registers company necessary documents shall be enclosed) ( )ResidentialAddressTel: [O][R]Fax/E-mail2 Details of Head of Unit, / Authorised signatory / Manager ( necessary documents shall beenclosed)\\ ( )ResidentialAddressTel: [O][R]Fax/E-mail4 Nature of of commencement of of member s of employer sfamilyemployed in the establishment,i

[FORM’A’] [See Rules 3(1), 3-A and 5] Combined Application for Registration/Renewal/Any change under Karnataka Shops and Commercial Establishments Act, 1961 and ...

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Transcription of [FORM’A’] [See Rules 3(1), 3-A and 5] Combined Application ...

1 [ form A ][See Rules 3(1), 3-A and 5] Combined Application for Registration/Renewal/Any change under Karnataka Shops and CommercialEstablishments Act, 1961 and Rules there underPART A1 Name of the establishment and : Fax: E-mail1 AName of the Head Office, if any withpostal address:Tel: Fax: E-mail2 Details of the Proprietor/ Managing Partner/ Director(In case of partnership or registers company necessary documents shall be enclosed) ( )ResidentialAddressTel: [O][R]Fax/E-mail2 Details of Head of Unit, / Authorised signatory / Manager ( necessary documents shall beenclosed)\\ ( )ResidentialAddressTel: [O][R]Fax/E-mail4 Nature of of commencement of of member s of employer sfamilyemployed in the establishment,indicate the relationship withthe employer :7 No.

2 Of of fees remitted(Receipt/ Challan No., Date, Amount) :9 Notified Weekly Holiday :PART BIn case of renewal, the following information shall be furnished in addition to theinformation in Part A1 Renewal for the yearsFrom:..To:..2 Original Registration Certificate No. :3 Ward No. and Date of issue / Circle :PART C1 Original Registration Certificate No. :2 Ward No. and Date of issue / Circle :The following changes have taken place in respect of information furnished in Part A( necessary documents shall be enclosed ) inPart APresent Description( Previsous declaration)Description after changeReasons for changeI / We hereby certify that the information furnished under Part A, B and C of thisCombined Application form , are complete and true to the best of my / our knowledgeand in case any information proved to be false, I/ We would be liable for legalconsequences.

3 Signature of Employer/ Authorised SignatoryPlace:Designation and Seal] form J( See Rule 22 )I hereby certify that, I have examined (Name)..Son/Daughter at ..and thathe/she has completed his /her fourteenth / seventeenth year impression P[ See Rule 24(4)]NOTICE OF HOLIDAYThe persons employed in ( name ofEstablishment) shall be given holiday on the day name below in the week following the date ofthis Notice & until further of employeeDay on which holiday is Q[ See Rule 24(9A)]APPOINTMENT & Address of & Address of the of the /Her Postal /Her permanent of of his/her entry of work entrusted to serial number in the Registerof of wages payable to allowances if ofr by the employee withdate & of the [ See Rule 24 B 9(1))

4 ] & Address of & Address of Address for Number of of Women Employees who are willing nto work during night &ResidentialAddress of ofworkMode ofTransportationprovidedWhether Securitywill be at other information employer mayalso wish to , of the employerFORM-UCOMBINED ANNUAL RETURN[(See Rule 24(9-C)]of Karnataka Shops and Commercial Establishment Rules , 1963) in lieu of1. form XXVV Rules 82(2) of Contract Labour (Regulation & Abolition ) Karnataka Rules , form III Rule 22(4) Karnataka Minimum Wages Rules , form XX Rule 20(1) of Karnataka Payment of Wages Rules , 20 Rule 16 of Karnataka Maternity Benefits Rules , of the Postal Address:1.

5 EstablishmentTelephoneLocationFaxAddress e-mail2. Registered office/ Head officeLocationAddress3. Name & residential address of the Employer or a person responsible for Conduct & control of BusinessNameDesignationResidential AddressTelephoneOfficeResidenceMobilee-m ail4. Name and Residential Address of the Manager/Authorized Signatory:NameDesignationResidential AddressTelephoneOfficeResidenceMobile-ma il5. Nature of business of the Establishment:6. A) Particulars of EmploymentNo. ofpersons on rollas on1-1-200(Yearcommencementdate)No.

6 Ofpersons onRoll as on31-12-200(Year enddate)No. of daysestablishmentworkedNo. of Man daysworked during theyearNo. of man hoursworked including the yearTotal amount ofsalary/wages paidincluding wagesand allowances (in Rs,)MenWomenTotal6. B) No. of employees whose employment is ceased:No. of employees discharged/ dismissed/terminated/ retrenched/ resigned/ retired duringthe yearAmount ofcompensation paidNo. of employeessuspended duringthe yearAmount ofsubsistenceallowance paid12347. Particulars of Earned Leave with WagesCategory ofemployeesTotal no.

7 Of personsemployedNo. of employeeseligible for earhedleaveNo. of employeesavailed\Grantedearned leaveNo. of employees paidwages/salary in lieu ofearned ) Menii)Women8. Whether the following Welfare measures are provided?1. Canteen2. Creches3. Shelters, Rest rooms and Lunch rooms4. Transport facility9. Maternity Benefit :A) Particulars of Maternity Benefits:1. Total No. of women workers who worked for a period of 160 days in the last 12 monthsimmediately preceding the date of delivery2. No. of women workers discharged/dismissed in the last 12 months3.

8 No. of women workers for whom pre-natal confinement and post-natal confinement isprovided by the employer with free of No. of women workers dieda. Before deliveryb. After delivery9-B Leave / additional leave details:ItemNo. of women applied for leaveLeave sanctionedLeave rejectedMiscarriageIllness(additional leave underSection 10)9-C Maternity Benefit paid:ItemNo. of ClaimsNo. of leavessanctionedNo. of claimsrejectedTotal benefit paid in Bonus10. Particulars of deductions made from salary(wages)No of employees involvedTotal amount of deductions madei) Finesii) Damages/ Lossiii) Breach of contractiv) OthersTotal11.

9 Contract Labour:Period of ContractNames and addressof the contractors FromToNature of workNo. ofcontractworkmenemployedNo. ofdays workedNo. ofmandaysworkedTotalCertified that the information furnished above to the best of my knowledge and belief, is :Signature of employer/ Manager/ Authorised SignatoryPlace:Name (IN CAPITALS)Designation.


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