Employer’s Code No. ____________________________

1.

Name of the Factory/Establishment

2.

Complete Postal Address of the Factory/Establishment

Pin

3.

a)               Telephone No., if any

b)               Fax No., if any

c)               E-mail address, if any

4.

Location of Factory/Establishment

a) State

b) District

c) Municipality/Ward

d) Name of Town/Revenue Village   

(Taluk/Tehsil)

e) Police Station

f) Revenue Demarcation/Hudbast No.

5.

Details of Bank Account

a)  Account No. ……………………….

b)  Account No. ……………………….

c)  Account No. ……………………….

Name of Bank and Branch

…………………………………………………

…………………………………………………

…………………………………………………

6.

a)  Income Tax PAN/GIR No.

b)  Income Tax Ward/Circle/Area

7.

a)  In case of factory whether Licence issued Under Section 2(m) (i) or 2(m) (ii) of the Factories Act, 1948

b)  Power Connection No.

No.

Sanctioned Power Load

Issuing Authority

8.

a)    Whether it is Public or Private Ltd., Company/ Partnership/Proprietorship/Cooperative Society/ Ownership (attach copy of Memorandum and Articles of Association/Partnership Deed/ Resolution

b) Give name, present and permanent residential address of present Proprietor/Managing Directors, Director/ Managing Partners, Partners/Secretary of the Cooperative Society.

i)

Name

Designation

Address

ii)

iii)

iv)

v)

vi)

vii)

9.

Address(es) of the Registered Office/Head Office/Branch Office/Sales Office/Administrative Office/other offices if any, with no. of employees attached with each such office and person responsible for the office.

Address as on Date

No. of Employee

Phone No./Fax No.

Work

Person responsible for day to day functioning of the office

(Give details on a separate sheet, if required.)

10.

a)       Whether any work/business carried out through contractor/immediate employer.

b)       If yes, give nature of such work/business