FORM - D (See rule 40) Statistics and Other Information 1. Name of factory/ establishment or contractor engaged in the manufacture of beedi. 2. Location and full postal address of factory /establishment /contractor. 3. Name of the employers of the factory /establishment /contractor and licence number issued by the Excise Department. (4) (a) Amount of tobacco for which licence is issued and actual amount for tobacoo received during the period from …………. To …………….. (b) Quantity of tobacco distributed and number of beedis manufactured from ………. to ………………. 5. Number of persons employed by the employers /contractors in factories/ establishments/private dwelling-houses during the period from ………….. 19 …………. to…………….. 19………….. Factories/ Establishment Private dwelling houses Male Female Children Total 6. Location of private dwelling houses where beedi is manufactured and their distance from factories/establishments. 7. Details of welfare facilities provided by the employers of the factory/establishment or contractor to persons employed by him. (A) Housing (B) Medical (C) Water Supply (D) Recreation (E) Any other activities. 8. Quantum of cess paid by the employer of the factory /establishment or contractor in the manufacture of beedi under the Beedi Workers Welfare Cess Act, 1976, during the period from ………………. To …………….. 19 ……………… 9. Any other information considered necessary regarding employment wages, welfare facilities allowed to the workers. Certified that the above particulars are true to the best of my knowledge and belief and are based on the records maintained in my establishment /factory. No. Employer of Factory/ Date and place Establishment /contractor FORM – D1 (See rule 40) 1. Name of the agency: 2. Year of formation of Agency: 3. Location and full postal address: 4. Name and full Postal address: 5. Whether the agency is a legal entity - (quote registration number, etc.) 6. Whether activities of the agency are open to participation by citizens of India irrespective of religion, caste, creed, sex or race: 7. Whether the agency is committed to secular and democratic concepts and methods of functioning: 8. Whether the agency has declared that it will adopt constitutional and non-violent means for achieving its objectives: 9. Object fives of the agency: 10. Work experience: 11. Length of experience: 12. Whether the agency has a declared constitution, memorandum, bye-laws, article of association (if yes, a copy thereof may be enclosed): 13. Whether the agency published a statement of accounts for the last year (if so, a copy thereof may be enclosed): 14. Any other information which the agency may consider necessary to furnish Certified that the above particulars are true to the best of my knowledge and belief and are based on the records maintained in my agency. Date and Place …………… Signature of Head of the Agency. NOTE. -The Welfare Commissioner may ask for any such other information, as he considers relevant in the matter.] 1. Added by G.S.R. 750, dated 22nd September 1989.
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