Form 4

(see rule 5(9) & 18)

Notice of Commencement / completion of work/ cessation of Establishment:

1. Registration No:

2. Name and Address of Factory or Establishment:

3. Name & Designation of occupier in case of factory or employer / Port authority(who has

ultimate control over the affairs of the establishment):

4. Full address to which communication relating to the factory or establishment to be sent:

5. Nature of work of the factory or establishment:

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

(establishment only):

7. in case of completion of work/cessation of establishment, the date of completion /cessation:

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

…………………………………..dated …………………………………… is likely to commence/cessation of work is likely

to be 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 occupier/employer

(Name and seal)

To,

The Inspector-cum-Facilitator