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Form of Annual Information On Factory/Establishment Cover Under Esi Act (Regulation 10C)

This document is a FORM-01(A) that collects annual information on factories/establishments covered under the ESI Act. It requests details such as the name and address of the factory/establishment, contact information, bank account details, income tax information, license details if applicable, ownership structure, addresses of offices, number of employees, and whether any work is contracted out. The form declares that the information provided is correct and undertakes to promptly notify any changes to the regional ESI Corporation office.

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hdpanchal86
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116 views

Form of Annual Information On Factory/Establishment Cover Under Esi Act (Regulation 10C)

This document is a FORM-01(A) that collects annual information on factories/establishments covered under the ESI Act. It requests details such as the name and address of the factory/establishment, contact information, bank account details, income tax information, license details if applicable, ownership structure, addresses of offices, number of employees, and whether any work is contracted out. The form declares that the information provided is correct and undertakes to promptly notify any changes to the regional ESI Corporation office.

Uploaded by

hdpanchal86
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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FORM-01(A)

FORM OF ANNUAL INFORMATION ON FACTORY/ESTABLISHMENT COVER UNDER ESI ACT (Regulation 10C)
Employers Code No. ____________________________ 1. Name of the Factory/Establishment

2.

Complete Postal Factory/Establishment

Address

of

the

Pin 3. a) b) c) 4. Telephone No., if any Fax No., if any E-mail address, if any

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 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)

8.

Nam e

Designati on

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) b)

Whether any work/business carried out through contractor/immediate employer. If yes, give nature of such work/business

I hereby declare that the statement given above is correct to the best of my knowledge and belief. I also undertake to intimate changes, if any, promptly to the Regional Office/Sub Regional Office, ESI Corporation as soon as such changes take place. Date Name & Signature

Place ..

Designation with seal .. (Should be signed by principal employer u/s 2(17) of ESI Act

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