Form 'B'


[See Rule 3(5)]

Statement of employers' contribution received by the Welfare Commissioner for six months ending on 30th June and 31st December respectively in the year ______________

Class of Establishment Number of establishment Amount of employers' contribution received by the Welfare
Commissioner
1 2 3
    Rs.
1. Factories
2. Motor Omni bus Service
3. Shops
4. Commercial establishments
5. Residential hotel
6. Restaurants
7. Eating house
8. Theatres
9. Other place of Public amusement or entertainment ______________________________________
  TOTAL ______________________________________


Signature of the
Welfare Commissioner

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Last Updated : 23 Mar,2014