| PROFORMA No.VII |
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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 Payment of Wages Act, 1936 and the Kerala Payment of Wages Rules, 1958 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/ License No. under the Factories Act,1948 or Kerala Shops and Commercial Establishments Act, 1960. |
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Name (s) and address (es) of the employer (s) with residential address (Please specify the Telephone no.) |
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Nature of manufacturing process/commercial/Industrial activities carried on |
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Present wage period (if different wage periods are observed for different categories that shall be specified) |
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Date of payment of wages (if different dates are fixed that shall be specified) |
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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 Payment of Wages Act, 1936 and the Kerala Payment of Wages Rules, 1958 to the extent applicable to the factory/ 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 Principal 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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| Copy to: |
The Regional Joint Director of Factories & Boilers/ |
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District Labour Officer (Enforcement) |
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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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