FORM 3: RETURN OF DECLARATION FORMS Regulation 14 Name and address of the factory or establishment .................................................................. Employer's Code No.................................................... I send herewith the declaration forms in respect of the employees mentioned below. I hereby declare that every person employed as an employee within the meaning of section 2 (9) of the Employees' State Insurance Act, 1948, on ...............in this factory or establishment and in receipt of a remuneration not exceeding Rs. 6500 per month has been included in this list (excepting only those in respect of whom declarations have been sent to the Corporation in the past). Place....................................... Signature...................................... Date ......................................... Designation ................................... Sl. No. | Name of the employee | Distinguishing No. with the employer, if any | Father’s/Husband’s name | Insurance No. allowed by the Corporation (to be entered at the appropriate office) | | | | | |
Enclosures: Signature ..................... Declaration Forms......................................... Designation ................ | 
