Form II

[(See rule 3(10)]

Application for cancellation of Registration Certificate of establishment

1.

Registration No:

2.

Name and Address of Establishment:-

3.

Name and Designation of employer :-

4.

Full address to which communication relating to the establishment to be sent :-

5.

Nature of work of the establishment :-

I/We here by intimate that the establishment having registration No. …………………….. dated………………….

is closed with effect from……………………………. (Date).

Certificate from Employer

I/we hereby certify that the payment of all dues to the workers employed in the establishment having registration no. ____ dated______ has been

made.

I/we hereby certify that the establishment having registration no. ____ dated______ kept free from storage of hazardous chemicals and substances.

[Strikeout whichever if not applicable]

Signature of the Employer

To,

The Registering Officer

The Inspector-cum-Facilitator

Place: Signature/ E-sign/digital sign of employer

Date: