| PROFORMA No.II |
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(Self certification for IT based Industries, IT enabled services, Bio-Technology establishments, Exports Oriented Units and Units in Export Processing Zones under the Maternity Act, 1961 and Kerala Maternity Benefit Rules, 1964 for the Calendar year ……) |
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Name & address of the Factory/Establishment (with building No., Telephone Nos. & PIN Code) |
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Registration/ Licence No. under the Factories Act, 1948 or the Kerala Shops and Commercial Establishments Act, 1960. |
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Name (s) & address of the occupier (s) with residential address (es) (please specify the Telephone No.) |
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Nature of service/commercial/industrial/manufacturing process carried on |
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Total number of workers employed |
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a) Permanent |
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Male |
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Female |
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Total |
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b) Temporary |
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Male |
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Female |
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Total |
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b) Others if any (Specify) |
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Male |
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Female |
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Total |
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| DECLARATION |
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| All the information furnished above are true and correct to the best of my/our knowledge, belief and information. |
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| Signature of Employer |
Signature of Manager |
| Name: |
Name: |
| Designation: |
Designation: |
| Date: |
Date: |
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| Office Seal: |
Office Seal: |
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| CERTIFICATE |
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1. Certified that I/ We have complied am/ are complying with all the statutory requirements under the Maternity Benefit Act, 1961 and the Kerala Maternity Benefit Rules, 1964 to the extent applicable to the Establishment. |
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2. I/We am/are the authorized person/s to issue this certificate and this is issued with full knowledge of the legal liabilities under this Act and Rules. I am/we are jointly and severally liable for any information found incorrect subsequently and liable for prosecution under this Act and Rules made there under. |
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| Signature of Employer |
Signature of Manager |
| Name: |
Name: |
| Designation: |
Designation: |
| Date: |
Date: |
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| Office Seal: |
Office Seal: |
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| (If more than one Employer, all of them shall sign and enter their details) |
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| Submitted to: |
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The Inspector of Factories and Boilers/ |
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Additional Inspector of Factories/ |
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Assistant Labour Officer/ |
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………………………………………………… |
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| Copy to: |
The Regional Joint Director of Factories & |
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Boilers/District Labour Officer (E) |
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| ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| FOR OFFICE USE |
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| Date of receipt of the proforma in the office of the Authority ………………………………… |
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| Remarks of the Authority if any, |
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Signature: |
| Office Seal: |
Name & Address of the Authority |
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| Place: |
| Date: |
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