Form III

(See rule- 5)

Notice of Commencement / cessation of operation 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:-

In case of notice of commencement of work:

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

dated………………… has commenced on.....................................(Date) and is likely to be completed

on….................................. (Date).

In case of notice of cessation of operation or completion of work:

I/we hereby intimate the completion of work / cessation of operation of the establishment having registration

No.……………dated........................on ..................... (Date) and 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.

* Strike off whichever is not applicable.

Signature of the Employer

To,

The Inspector-cum-Facilitator

..................................................... (office)