Form IV

(See Rule-3(9) and Rule-5)

A- Notice of Commencement / cessation of Establishment:

1. Registration No:

2. Name and Address of Establishment:-

3. Name & Designation of employer (who has ultimate control over the affairs of the

establishment :-

4. Full address to which communication relating to the establishment 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, the date of cessation:

I/We hereby intimate that the work of establishment having registration No.

dated is likely to commence/cessation 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