Form XXI

[See Rule 61(3) (a)]

APPLICATION FOR REGISTRATION OF AN ESTABLISHMENT WITH THE COMPETENT

AUTHORITY UNDER SECTION 57

1. Name of the Establishment

2. Address of the Establishment

3. Name of the Employer(s)

4. Address of the Employer

5. Name and address of Manager/ Agent/ Person responsible for supervision and control

6. E-mail address/ Telephone or Mobile Number

7. No. of Employees Insured

8. Details of the Insurance Company—

(a) No. of Insurance Policy ;

(b) Date of Commencement of Insurance Policy ;

(c) Terms of Insurance Policy (copy of the Insurance Policy to be enclosed)

(d) Details of employees insured shall be furnished in Form – XXII.

9. If the employer had already established an Approved Gratuity Fund before notification of the

rules, details of Board of Trustees of the gratuity fund may be furnished—

(a) Date of constitution of the Board of Trustees;

(b) Names and Addresses of the Board of Trustees.

Place :

Date : Signature of the Employer

Name & Designation and Address