Form VI

Part - A

[See sub rule (1) of rule 54]

APPLICATION UNDER SUB-SECTION (4) OF SECTION 56 FOR COMPOSITION OF OFFENCE

1. Name of applicant :

2. Father’s / Spouse name :

3. Address of the applicant :

4. Particulars of the offence:….. ..…………………………………………………………………………

…………………………………………………………………………………………………………………

5. Section of the Code under which the offence is committed :

……………………………………………………………..

6. Maximum fine provided for the offence under the Code :

………………………………………………………………….

7. Whether prosecution against the applicant is pending or not

……………………………………………………..

8. Whether the offence is first offence or the applicant had committed any other offence prior to the

offence. If yes, then, full details of the prior offence.

…………………………………………………………………………………………………………………

9. Any other information which the applicant desires to provide

…………………………………………………………………………………………………………………

Applicant (Name and signature)

Dated:

PART – B

[See rule 54 (3)]

Composition Certificate

Ref: Notice No………….. Date:

This is to certify that the offence under sub-section …… of section 54 in respect of which Notice No. Dated: _____ was

issued to Sh…………. (Applicant), the employer of ……………. (name and registration number of establishment) has been

compounded on account of remission of full amount of Rs ……….. (Rupees _________________) towards the composition

of offences to the satisfaction of the said notice.

(Signature)

Name and Designation of the Officer

Date:

Place:

To:

………………..(Employer/Establishment)

…………………(Name and registration number)

………………….(Address)