1. Reg. No

2. Name and address of the factory

3. Name of occupier

4. Name of section or department which has closed (If the whole factory has closed please write ‘Total closure’

5. Date of closure

6. Reasons of closure

7. Whether the closure is permanent or temporary

8. Probable period of closure

9. Intended date of re-opening

10. No. of workers on the register or part of the factory which is closed on the date of closure

11.No. of workers affected by the closure

12.Information required as per the provision of subrule (3) of rule 127 in respect of chemicals stored (add separate sheet) .

13. Remarks