Download Employees State Insurance - Return of Declaration

nks izfr;ksa esa In Duplicate deZpkjh jkT; chek fuxe izi=k . Form 3 EMPLOYEES' STATE INSURANCE CORPORATION ?kks"k.kk i=k fooj.kh Return of Declaration Form [fofue; Regulation 14] dkj[kkus ;k izfr"Bku dk uke rFkk irk ............................................................................................................................................ Name & Address of factory or Establishment eSa buds lkFk uhps fn;s gq, deZpkfj;ksa ds ?kks"k.kk i=k vkidh lsok esa izsf"kr djrk gwaA eSa ,rn~}kjk ?kksf"kr djrk gwa fd eSa deZpkjh jkT; chek fuxe vf/kfu;e dh /kkjk ¼ ½ dh ifjHkk"kk ds vUrxZr izR;sd deZpkjh tks bl dkj[kkus ;k izfr"Bku esa fnukad ............................ dks dk;Z dj jgs gSa vkSj # ] @& ls vf/kd ikfjJfed ¼vfrfjDr dk;Zdky dk ikfjJfed NksM+dj½ izfrekg ugha ik jgs gSa bl lwph esa lfEefyr dj fy;k x;k gS ¼dsoy mUgsa NksM+dj ftuds ?kks"k.kk i=k fuxe dks igys gh Hksts tk pqds gSa½ I send herewith Declaration Forms in respect of the employees mentioned below. I hereby declare that every person employed as an employee within the meaning of Section 2(9) of the Employees' State Insurance Act, 1948 on ............................... in this factory or establishment and is respect of a remuneration not exceeding Rs. 10,000/- (excluding remuneration for overtime work) per month has been included in this list (excepting only those in respect of whom declaration forms have been sent to the Corporation in the past). LFkku Place ............................................. LFkkuh; dk;kZy; ...................................... gLrk{kj Signature ..................................... fnukad Date ............................................. Local Office ......................................... in Designation ........................................ Ø­la-S. No. deZpkjh dk uke Name of the Employee fu;kstd ds ikl igpku la[;k ;fn gks Distinguishing No. with the employer if any firk ;k ifr dk uke Father's or Husband's Name fuxe }kjk fu;r chekad ¼LFkkuh; dk;kZy; ls vafdr gksuk pkfg,½ Insurance No. allotted by the Corporation (to be entered at the appropriate Local Office) .......... ........................................................ ................................. .............................................. .................................................... layXu ?kks"k.kk i=k Encl. Declaration Form P.T.O. Ø­la-S. No. deZpkjh dk uke Name of the Employee fu;kstd ds ikl igpku la[;k ;fn gks Distinguishing No. with the employer if any firk ;k ifr dk uke Father's or Husband's Name fuxe }kjk fu;r chekad ¼LFkkuh; dk;kZy; ls vafdr gksuk pkfg,½ Insurance No. allotted by the Corporation (to be entered at the appropriate Local Office) .................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... .................................................... vfxze i`"B Continuation gLrk{kj Signature ............................