Form B1 ( Registration/ Renewal)

FORM No.B1

(See Rule 2A and B)

                                                                                      Regn.Certificate.No: …………

Application for grand of the renewal / Registration Certificates for the year………..

1. Full name of Establishment                                :

2. (i)   Full address of establishments                     :

                   with Door No. Street etc.

(ii)     Full address to which communications                    :

        relating to the Establishments should be sent

(iii)    Name and full address of the Employer                  :

3. whether Shop or Commercial Establishment                  :
4. (a) The No. and Name of employees in the

             Establishment during the current year

      (b) The No. and Name of employees in             :

             the Establishment during the previous year

(a list of names be attached)

5. (a) Full Name and Residential Address of the who         :

            shall be the Employer for the purpose of the Act.

      (b) Full Name and Residential Address of the whom      :

            shall be the Manager for the purpose of the Act.

6. If the employer is a partnership company etc.    :

       full name and residential address of the

      other partners or Directors etc.

Amount Fee Rs :………….( Rupees………………………………………….….) paid in Treasury on…………………..Vide Chelan No………… dated:………… enclosed.

I hereby declare that the particulars furnished by me in the form are correct to the best of my knowledge and belief.

Date:                                                                            Signature of the Employer