Download Application Form for Shops and Establishment Licence, Form D - Vadodara

Statement under section 7(6) [See Rule 7] ÅÛ¾Û 7(6) Ð ¥ Ç¶Û × ÜÈÛÈÛÁ ¨Û ¸ÛªÛ [ .Û Û¶Û ¶Û 7] FORM " D " ¶Û¾Û ¶ÛÛ " ¦ " 1. Name of the establishment ÍÛ×ͬÛÛ¶Û × Û ¶ÛÛ¾Û Ð Û ¿Û ©ÛÛ : 2. Postal address and situation of the establishment : ÍÛ×ͬÛÛ¶Û ¤ ¸ÛÛÅÛ¶Û × ÍÛÁ ¶ÛÛ¾Û × .¶Û ͬÛÇ¶Û ÜÈÛ Û©Û 3. Situation of office, storeroom, godown, warehouse, or workplace if any, attached to a shop but situated in premises different from those of the shop. : - Û¶Û ÍÛÛ¬Û Û ¦ Û¿Û ÅÛ ¸Û¨Û - Û¶Û¶ÛÛ Í¬ÛÇ¬Û .ÅÛ Û Í¬ÛÇ .ÛÈÛ ÅÛ Û Á -ͤ Û Á Ä ¾Û- ÛÛ - Û¾Û-ÈÛ"ÛÛÁ Û¾Û¶Û × Í¬ÛÇ Ð Û ¿Û ©ÛÛ ©Û ͬÛÇ .× Û ¶Û ÜÈÛ Û©Û. 4. Name of the employer ¾ÛÛÜÅÛ ¶Û × ¶ÛÛ¾Û : 5. Residential address of the employer ¾ÛÛÜÅÛ ¶ÛÛ Á Ð ¥ Û¨Û¶ÛÛ Í¬ÛÇ¶Û × ÍÛÁ ¶ÛÛ¾Û ×. : 6. Name of the Manager if any, and his residential address. : Û Ð Û ¿Û ©ÛÛ È¿ÛÈÛͬÛÛ¸Û ¶Û × ¶ÛÛ¾Û .¶Û Á Ð ¥ Û¨Û¶Û × ÍÛÁ ¶ÛÛ¾Û ×. 7. Category of the establishment i.e. whether shop, commercial establishment, residential hotel, restaurant, eating house, theatre or other place of public amusement or entertainment. : ÍÛ×ͬÛÛ¶ÛÛ ¸Û ÛÁ . ¤ ÅÛ - Û¶Û, ÈÛ ¸ÛÛÁ ÍÛ×ͬÛÛ, Á Ð ÈÛÛ¶Û ÍÛ ÛÈÛ¦ µÛÁ ÛÈÛ©Û Ð Û ¤ ÅÛ, Á ͤ Û Á Û×, ½ÛÛ ¶ÛÛÅÛ¿Û, ¬Û . ¤ Á .¬ÛÈÛÛ .Û¶Û×- ¸Û ¾ÛÛ - ¾Û¶ÛÛ Á× ¶Û ¾ÛÛ¤ ¶Û × .¶¿Û ÛÐ Á ͬÛÇ ¾Û? 8. Nature of business Û¾Û Û ¶ÛÛ ¸Û ÛÁ : 9. Date of commencement of business µÛ×µÛÛ ÉÛÄ ¿ÛÛÙ¶Û ©ÛÛÁ "Û : 10. Name of members of business family employed in the establishment Adult men ________ Adult women ______ Young persons _______ Total _______ ÍÛ×ͬÛÛ ¾ÛÛÜÅÛ ¶ÛÛ ¸ÛÛ ©ÛÛ¶ÛÛ ¤ × ¼Û ¶ÛÛ ÍÛ×ͬÛÛ¾ÛÛ× ¶ÛÛ Á . : Á Û"ÛÈÛÛ¾ÛÛ× .ÛÈ¿ÛÛ Ð Û ¿Û ©ÛÛ ©Û ¾Û¶ÛÛ ¶ÛÛ¾ÛÛ ¸Û "©Û ÈÛ¿Û¶ÛÛ ¸Û  ÌÛ ________ ¸Û "©Û ÈÛ¿Û¶Û ÍªÛ .Û _______ ¶ÛÛ¶Û ÈÛ¿Û¶ÛÛ× ________ ÅÛ _________ 11. Name of other persons occupying position of Management or Employees engaged in confidential capacity (indicate sex and age in case of young persons). È¿ÛÈÛͬÛÛ ©Ûת۾ÛÛ× Ð Û ° Û µÛÁ ÛÈÛ©Û .¶¿Û È¿ÛÜ ©Û .¬ÛÈÛÛ : ÜÈÛÊÈÛÛÍÛ¸ÛÛªÛ È¿ÛÜ ©Û.Û ¶ÛÛ ©ÛÁ Û¾Û¾ÛÛ× Á "ÛÛ¿Û ÅÛ È¿ÛÜ ©Û.Û ¶ÛÛ ¶ÛÛ¾Û (¶ÛÛ¶Û ÈÛ¿Û¶ÛÛ È¿ÛÜ ©Û.Û ¶Û ¼ÛÛ¼Û©Û¾ÛÛ× ÛÜ©Û .¶Û ÈÛ¿Û - ÉÛÛÙÈÛÈÛ ) 12. Total number of employees: Adult men _______ Adult women ______ Young persons ______ Total ______ ¶ÛÛ Á ¿ÛÛ©ÛÛ ¶Û ÅÛ ÍÛ×"¿ÛÛ: : ¸Û "©Û ÈÛ¿Û¶ÛÛ ¸Û  ÌÛ _______ ¸Û "©Û ÈÛ¿Û¶Û ÍªÛ .Û ______ ¶ÛÛ¶Û ÈÛ¿Û¶ÛÛ× _______ ÅÛ _________ 13. Registration No. and Date ¶ÛÛ µÛ¨Û ¶Û×¼ÛÁ .¶Û ©ÛÛÁ "Û : 14. Date of last renewal ÅÅÛ ©ÛÛ Á ÛÈ¿ÛÛ¶Û ©ÛÛÁ "Û : Date ©ÛÛÁ "Û Signature of the Employer ¾ÛÛÜÅÛ ¶Û ÍÛÐ Note:­ 1. This statement shall be sent to the Inspector of the local area concerned with such face as are prescribed schedule. 2. Item 3 should be filled only when the office, storeroom, etc. is not separately registered under the Act, in respect of such office, storeroom, etc. particulars are required under 10, 11 & 12 should be given separately in this statement. 3. The Original Certificate in C shall be enclosed. 4. If the number of employers is more than one, then names and residential address of all employers shall be given in items 4 & 5 respectively. 1. .¶Û ÍÛ Û [2] ¾ÛÛ× ¥ Á ÛÈÛ ÅÛ º ÍÛÛ¬Û ÅÛÛ Û©ÛÛ ÈÛÇ Û©ÛÛ ÜÈÛÍ©ÛÛÁ ¶ÛÛ Ü¶ÛÜÁ "Û ¶Û ÜÈÛÈÛÁ ¨Û ¸ÛªÛ ¾ÛÛ ÅÛÈÛ ×. 2. Û Á , ͤ Û Á Ä ¾Û ÜÈÛ Û Á ¶Û .Û Ü¶Û¿Û¾Û¶Û Ð ¥ Ç .ÅÛ Û Á ©Û ¶ÛÛ µÛ¨Û ¶Û Á Û Ð Û ¿Û ©¿ÛÛÁ ¼ÛÛ¼Û©Û 3 ½ÛÁ ÈÛ . .Û Û Á ¾ÛÛ× Í¤ Û Á Ä ¾Û ÜÈÛ Û Á .× Û ¼ÛÛ¼Û©Û 10, 11 .¶Û 12 Ð ¥ Ç .Û¸ÛÈÛÛ¶Û ¬Û©Û ÜÈÛ Û©ÛÛ .Û ÜÈÛÈÛÁ ¨Û ¸ÛªÛ ¾ÛÛ× .ÅÛ Û .Û¸ÛÈÛ . 3. ¶Û¾Û ¶ÛÛ " ÍÛ " ¾Û ¼Û¶Û × ¸Û ¾ÛÛ¨Û¸ÛªÛ ÍÛÛ¬Û ¼Û ¦ ÈÛ ×. 4. Û ¾ÛÛÜÅÛ Û ¶Û ÍÛ×"¿ÛÛ . ¬Û ÈÛµÛÛÁ Ð Û ¿Û ©ÛÛ ¾ÛÛÜÅÛ Û ¶ÛÛ ¶ÛÛ¾ÛÛ .¶Û ÍÛÁ ¶ÛÛ¾ÛÛ .¶Û . ¶Û×.4 .¶Û ¸Û ¾ÛÛ× - ÉÛÛÙÈÛÈÛÛ. .Û Û ÅÛ¾Û 18 (1) ¸Û Ü©Û, ¼ÛÛ ¾¼Û ÉÛÛ ¸¡ . ¶¦ . ͤ Û¼ÅÛ ÉÛ¾Û ¶¤ 1948 .¶ÈÛ¿Û ¶ÛÛ ¶Í¸Û ¤ Á 1. ¾ÛÛÜÅÛ ¶Û × ¶ÛÛ¾Û: ________________________________________________. 2. ÍÛ×ͬÛÛ¶Û × ¶ÛÛ¾Û Û Ð Û ¿Û ©ÛÛ : ________________________________________________. 3. ÍÛ×ͬÛÛ¶Û × ¤ ¸ÛÛÅÛ¶Û × ÍÛÁ ¶ÛÛ¾Û ×: ________________________________________________. 4. Á ͤ Á ÍÛ¤ º ¤ ¶Û×¼ÛÁ : ________________________________________________. 5. µÛ×µÛÛ¶ÛÛ ¸Û ÛÁ : ________________________________________________. .¾ÛÛ .¾ÛÛÁ ¸ÛÁ ¨ÛÛÈÛ ÅÛ ÍÛ×ͬÛÛ / ¸Û § ÛÛÅÛ ÍÛÛÅÛ ____________________ ¬Û ÉÛÄ ¬Û©ÛÛ× ÈÛÌÛÙ¾ÛÛ× ©ÛÛÁ "Û ____________ ¬Û ©ÛÛÁ "Û ____________ ÍÛ µÛ - Á ______________ ÈÛÛÁ ¶ÛÛ Á Û ¼Û×µÛ Á Û"Û .¥ ÈÛÛܦ Á Û ¸ÛÛÇ ÉÛ × ©Û ¶Û ¶ÛÛ µÛ ÅÛ ÉÛÛ . ©ÛÛ. ____________ ¾ÛÛÐ ____________ ÈÛÌÛÙ ____________ ¾ÛÛÜÅÛ / ¾Û ¶Û Á ¶Û ÍÛÐ