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Form 'A' |
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ANNEXURE
FORM 'A'
[See Rule 3(4)]
Statement of employees' and employers' contribution for the six months ending on the 30th June and the 31st December, respectively
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| 1. |
Name of the establishment |
| 2. |
Name of the employer |
| 3. |
Class of establishments (i.e. whether a factory of motor omni bus service, a shop, commercial establishment, residential hotel, restaurant, eating house, theatre or other place of public amusement or entertainment). |
| 4. |
Address of the establishment |
| 5. |
Total number of employees whose names stands on the establishment register on the 30th June/the 31st December. |
| 6. |
| (a) |
Employees' contribution at the rate of Rs._________ |
| (b) |
Employers' contribution at the rate of Rs. _________ Per employee, | |
| 7. |
Total of sub-entries (a) and (b) of entry 6. |
| 8. |
Weather the contribution has already been paid to the Welfare Commissioner, if so, whether by cheque, money order or cash and details thereof. | | |
Signature of the employer.
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