Form VI

[See rule 44]

Employer / Pay-in-charge signature

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: ………………………………………………………

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

6. Maximum fine provided for the offence under the Code: ……………………………

7. Whether prosecution against the applicant is pending or not …………………………

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

…………………….………………………………………………………………………………………

…………………….………………………………………………………………………………………

9. Any other information which the applicant desires to provide

…………………….………………………………………………………………………………………

…………………….………………………………………………………………………………………

Dated:

Applicant

(Name and signature)