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Esi Application Form

ESI APPLICATION FORM

Uploaded by

Sathish manickam
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© © All Rights Reserved
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42 views

Esi Application Form

ESI APPLICATION FORM

Uploaded by

Sathish manickam
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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FORM 01(A)

E.S.I ANNUAL INFORMATION EMPLOYEES DETAILS:


1) Name and Address of the factory

2) Employers Code number

: 56-00-

3) State / district

: TAMILNADU / COIMBATORE

4) Nearest police Station

5) Name of the Town / Revenue Village :


6) Name of Taluk / Tehsil

7) Hudbast / Revenue Demarcation

8) Municipality / Ward Number

9) Phone Number / Mobile number

10) Fax number

11) E-mail Address

12) Bank Details Bank Name

Bank branch Name

Account Number

MCIR Code of the Bank

IFSC Code of the Bank

13) Principal Employers Name / Age /


Designation / Fathers Name and
Address
:
14) Number of Employees

15) Name & Address of the responsible


Person Particulars / Factory / Offices
Phone No. / Mobile / Fax No. / Email:

Coimbatore / Ward No.

16) Income Tax pan No./ GIB No./ Ward :


17) Power Connection Number
:
Power Sanctioned Load / Issue. Auth :
18) Constitution of Ownership

/TNEB-CBE
Prop/ Partnership /Pvt/ Pub.

19) Responsiblepersons Name / Address : as above


20) Any other work thro Contract / Immediate Employer / Branch /
Nature Of such work / business
:
21) ESI Branch Office / Inspn. Divn

: PMDU

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