[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 :Signature of Employer/ Authorised SignatoryPlace:Designation and Seal] form J( See Rule 22 )I hereby certify that, I have examined (Name).

3 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))] & 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.

4 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. 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.

5 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. 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.

6 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. 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.

7 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.