Form IV

(See Rule-5 (10) and Rule- 7)

Notice of Commencement / cessation of Establishment:

1. Registration No:

2. Name and Address of Establishment:-

3. Name & Designation of employer/ who has control over the affairs of the establishment:-

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

5. Nature of work of the establishment:-

6. In case of the notice is for commencement of work, the approximate duration of work:-

7. in case of cessation of establishment, the date of cessation:

I/We hereby intimate that the work of establishment having registration

No.…….....................................…….dated is likely to commence/ cessate or is likely to be

completed with effect from………………….. ……………………………………………..............…

(Date)/On ..........................................................................................................................(Date)

In case of cessation of work:

I/we hereby certify that the payment of all dues to the workers employed in the

establishment have been made and the premises are kept free from storage of hazardous

chemicals and substances.

Signature of the Employer

To,

The Inspector-cum-Facilitator