2. If the Establishment is already covered then M H 0 0 1 7 8 3 A W B S L G 0 0 0 3 8 8 3. * Status / Ownership Type ( Please Mention exact code from the List Below.) COMPANY 1 0 PARTNERSHIP 2 0 CO-OPERATIVE SECTOR 3 0 PROPRIETORSHIP 4 0 OTHERS 9 9 TRUST 5 0 (If Others) Please specify 4* Incorporation / Setup Details 4a. In case Registered as Factory Factory Licence No. Licence Date / / D D M M Y Y Y Y Date Of Trail Production / / D D M M Y Y Y Y 4b Date of Incorporation / Setup / / D D M M Y Y Y Y 4c. Place of Incorporation /Setup District/City State Pin-code (I) Name of The Issuing Authority (II) Agency / Authority Code No. (III) Date of Issue / / Expiry Date / / D D M M Y Y Y Y D D M M Y Y Y Y 4e. Describe Establishment's prime (In terms of revenue shareor people employed) economic / business activity mentioning main product and process Other Activities 4f. 5. Employee Details (Including all branches,units etc.) 5a. Date on which Employee Strength Exceeded 19 (4 in case of Cinema) / / For the first time from the setup / incorporation date D D M M Y Y Y Y 5b.* Employee Strength on the date of filling this form 5c. Total Wages Paid In Previous Month (In Nearest Rupees) 5d.* JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 5e.* Is the Establishment Seeking Voluntary Coverage Yes No 5f. If Yes, then date from which coverage is sought / / D D M M Y Y Y Y 5h. Reason For Voluntary Coverage 6 Other Supporting Government Codes (If any) D D M M Y Y Y Y a. Small Scale Industries Reg. No. / / b. IT-PAN as given by the Income Tax Department / / c. Employee State Insurance Corporation / / d. General Sales Tax No. / / e. Central Sales Tax No. / / f. EXIM Code No. / / g. Excise Dept Reg. No. / / h. Custom Dept Reg. No. / / I. RBI Registration No. / / j. IRDA Reg. No. / / k Apparel Export Promotion Council Reg. No. / / l Directorate Of Education Reg. No. / / m CBSE Reg. No. / / n Directorate Of Health Service Reg. No. / / o Food Controller Reg. No. / / p Drug Controller Reg. No. / / q Electricity Connection No. / / r Water Connection No. / / s Other Government Code / / Name Of the Issuing Authority EMPLOYEES' PROVIDENT FUND ORGANIZATION Form For Allotment Of Business Number (BN 4d. Please Specify The Supporting Government Code for the Ownership Type If the exact 5 digit NIC'98 code for your establishment's prime business/economic activity is known then please mention it here / / / Example MH/1783/A should be written as / / / // / PLEASE FILL ALL THE FIELDS IN CAPITAL ENGLISH LETTERS USING BLUE/BLACK BALL POINT PEN ONLY, FIELDS MARKED ( * ) ARE MANDATORY. REFER INSTRUCTION SHEET FOR GUIDELINES ON FILLING THE FORM The Establishment Code No. 1. * Full name of the establishment /factory (as registered with Income Tax department,Registrar of Companies or any other government authority WB/SLG/388 should be written as Year(Not For Data Capture) (If Any) Please mention the employee strength for each month (for previous 36 months) Code Issue Date Page 1 of 2 Yes No 7b. If Yes, then please mention the total number of branches,units and subsidiaries excluding the Registered / Head Office Please furnish an annexure of addresses (in the exact format mentioned in the item 8,9,10 above) for all the branches / units/ subsidiaries 8. Address of the Establishment (PLEASE FILL THE COMPLETE ADDRESS, ALL CORRESPONDENCE WILL BE DONE TO THIS ADDRESS) a.* Serial Number (Starting With 0001 for HQ / Regd. Office / Factory) b. House/ Door/Flat/Block No. (30 Blocks) c. Name Of Premises / Building / Village (30 Blocks) d Road / Street / Lane / Post Office (30 Blocks) e. Area / Locality/Taluka/Sub Division (30 Blocks) g. * State / Union Territory (30 Blocks) S T D N U M B E R j * Phone No. + k FAX No. l Mobile No. m E-mail Id 9.* Complying Independently with EPFO (Tick mark) Yes No If No, then Please mention the Branch Serial No.Under (through) which the branch complies with EPFO 10. Details of Person for Co-ordination & follow up a Contact Person Name b. Designation S T D N U M B E R c. Phone No. + d. Fax No. e. Mobile No. f. E-mail Id 11. * Verification By Employer a. Name,Signature and Stamp of Applicant / Authorized Signatory Seal of Establishment Name Signature b. Date / / D D / M M / Y Y Y Y c. Place 12. List Of Enclosures (Tick mark if attached) Photocopy of Code No. letter Issued by EPFO as per Item 2. Registration Information as mentioned in Item 4c. (i.e. supporting government code for the declared ownership type) Employee & Employer Consent for Item 5e. (if applicable) List of branches as mentioned in item 8,9. Other Encl. (for item 6) ( a ) ( b ) ( c ) 13. For Office Use Only a. Form Received On / / b. Form Number D D / M M / Y Y Y Y / / d. Checked By D D / M M / Y Y Y Y f. Allotment Date / / D D / M M / Y Y Y Y g. Coverage Under Section h. In case the application is rejected, Reason c. Data Entry Done On 7a. * Are There any branches / units / subsidiaries to your Establishment ? (Tick mark) e. BN Allotted i. * P
