Form VI

Part-A

[See sub-rule (1) of rule 45]

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: ………………………………………………………

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

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6. Maximum fine provided for the offence under the Code

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7. Whether prosecution against the applicant is pending or not

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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.

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9. Any other information which the applicant desires to provide

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Applicant

(Name and signature)

Dated:

PART – B

[See rule 45 (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 Shri/Smt/Kum………….

(Applicant), the employer of ……………. (name and registration number of

establishment) has been compounded on account of remission of full amount of

Rs ……….. (In words 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)