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(See rule 41)

  1. Name and address of the employer
  2. Whether Head Office Branch Office
  3. Nature of business/ principal activity
  4. Total number of persons on the pay-roll of the establishment. (This figures should include every person whose wage or salary is paid by the establishment).
  5. Total number of disabled persons (disability-wise) on the payroll of the establishment. (This figure should include every person with disability whose wage or salary is paid by the establishment).
  6. (a) Occupational qualification of all employees as given in item-5 above. (Please give below the number of employees in each occupation separately.)
    (b) Please indicate the main reasons for any increase or decrease in employment if the increase or decrease is more than 5% during the quarter ..............
  7. Vacancies : Vacancies carrying total emoluments as per prevailing minimum wage per month and of over three months duration.

    (a) Number of vacancies occurred and notified during the quarter and the number filled during the quarter.

    Number of vacancies which come within the purview of the Act
    Occurred Notified   filled Sources
      Local Special Employment Exchange General Employment   (Describe the Source from which filled).
    1 2 3 4 5

    (b) Reasons for not notifying all vacancies occurred during the quarter under report vide (a) 2 above .............

    Manpower Shortages

    Vacancies posts unfilled because of shortage of suitable applicants

    Name of the Number of unfilled Vacancies/posts
    occupation or designation of the posts essential qualification essential experience experience not necessary
    1 2 3 4
Please list any other occupations for which this establishment had recently any difficulty in obtaining suitable applicants.

Signature of Employer
(F.No. 16-7/96-NI.I)
Gauri Chatterji, Jt. Secy.

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