FORM D
[See Sec. 4(l) proviso (b) (i)]
Monthly register showing welfare amenities to be maintained by small establishments
Name and address of the                    Address of the establishment: For the month of...
Employer………………                 Local/Permanent

S. No	Name of the employee	Sex	Designation	Weekly day of rest	Dates of holidays for festival           or similar other occasions	Number of    casual leave availed by the employee
1	2	3	4	5	6	7

Quantum of annual leave with wages		Whether Welfare Amenities provided for
Due	Availed	Rest room	Drinking water	First aid
8	9	10	11	12

Whether Scheduled Caste/Scheduled Tribe, Handicapped or any other particular category	Signature of the employer or his agent	Remarks of the Inspecting Officer	Signature of Inspector with date
13	14	15	16

NOTE : To be completed within seven days of the expiry of each calendar month.
Signature of the employer with full name in capitals.
Date…………………
Place………………..