Form XII (D)

[See rule 141(2)]

Notice to the employer for an offence committed under the

provisions of the Code for the first time for composition of offences

Notice No…………… Date:

On the basis of records and documents produced before me, the

undersigned has reasons to believe that you, being the employer of the

establishment…………….. (Registration No………….), have committed an offence

for the violation of provision of the Code or the Schemes or the Rules or the

Regulations or the Standards framed there under as per the details given

below:-

PART – I

1 Name of the person:

2 Name and Address of the establishment :

3 Registration No. of the establishment:

4 Particulars of the offence:

5 Provisions of the Code/Scheme/ Rules/

Regulations under which the offence is

committed:

6 Amount required to be paid for

compounding of the offence:

7 Name and details of account for

depositing the amount specified in serial

no. 6:

PART –II

In view of the above, you have an option to pay the entire amount

mentioned at serial no. 6 in Part-I within fifteen days from the date of issue

of this notice and return the application duly filled in Part – III of this notice.

In case the said amount is not paid within the specified time, necessary

action for institution of prosecution shall be initiated without giving any

further opportunity in this regard.

Date:

Place:

(Signature)

Name and designation of Officer)

To:

………………..(Employer/Establishment)

…………………(Name and registration number)

………………….(Address)