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    Self Declaration Form PDF

    Uploaded by

    Aayush Agarwal
    The document outlines a self-declaration certificate format for entrepreneurs to complete during the lockdown period. It requests information about the applicant firm including name, address, factory location, contact details, product/activity details, number of workers, and arrangements for worker housing and safety. The certificate declares that the unit falls under exempted categories as per lockdown orders, and that all social distancing and safety protocols will be followed. It warns that any false information could lead to legal action.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Self Declaration Form PDF

    Uploaded by

    Aayush Agarwal
    304 views3 pages
    The document outlines a self-declaration certificate format for entrepreneurs to complete during the lockdown period. It requests information about the applicant firm including name, address, factory location, contact details, product/activity details, number of workers, and arrangements for worker housing and safety. The certificate declares that the unit falls under exempted categories as per lockdown orders, and that all social distancing and safety protocols will be followed. It warns that any false information could lead to legal action.

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    Self Declaration Form.pdf

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    The document outlines a self-declaration certificate format for entrepreneurs to complete during the lockdown period. It requests information about the applicant firm including name, address, factory location, contact details, product/activity details, number of workers, and arrangements for worker housing and safety. The certificate declares that the unit falls under exempted categories as per lockdown orders, and that all social distancing and safety protocols will be followed. It warns that any false information could lead to legal action.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    304 views3 pages

    Self Declaration Form PDF

    Uploaded by

    Aayush Agarwal
    The document outlines a self-declaration certificate format for entrepreneurs to complete during the lockdown period. It requests information about the applicant firm including name, address, factory location, contact details, product/activity details, number of workers, and arrangements for worker housing and safety. The certificate declares that the unit falls under exempted categories as per lockdown orders, and that all social distancing and safety protocols will be followed. It warns that any false information could lead to legal action.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Format of Self-declaration Certificate by the Entrepreneur

    Part One:

    For completion by the Applicant Firm/Company/LLP/Trust/Society


    Name

    Address

    Location of Factory/Establishment

    Udyog Adhar Registration No.


    Contact No. & Mobile No.

    Email Address

    Name of Product/Activity

    Total workers in unit on payroll

    Total workers in unit through


    contractor
    Whether workers are staying in
    factory premises, if yes, how many
    Name and Mobile Number of
    Responsible Person of Unit
    Whether situated within Municipal
    limit or Rural Area, specify name
    Shifts to be operated during lockdown
    period
    Whether labours staying within
    premises or not, if yes, how many
    Do you have adequate arrangements Yes/No
    for staying and other needs of the No. of Rooms No. of Bedroll
    workers? If yes, specify Mode of food supply on daily basis:
    Do you have adequate arrangements
    of safety and social distance as per
    orders of Govt.
    No. of workers/personnel coming
    from outside during operation of
    activities of factory/establishment
    Part Two:
    I……………………………….. Son/Daughter/Wife of Shri ………………………..
    resident of …………………………………. is Owner/ Director/Partner/Manager/
    Authorized person of above named applicant and duly authorized to furnish this self
    declaration certificate on behalf of applicant firm/company/Trust/Society. I Solemnly
    affirm and declare that our unit/activity falls under exempted category under Lockdown
    Period in accordance with the Order No. 40-3/2020-DM-1(A) dated 15.04.2020 issued by
    Ministry of Home Affairs, Government of India and Order No. F.33(2) Home/ Gr.9/2019
    dated 15.04.2020 read with Order dated 26.03.2020, 04.04.2020 & 07.04.2020 issued by
    Home Department, Government of Rajasthan and any subsequent orders to be issued in
    this regard.

    I affirm and certify that I have understood the terms and conditions of the cited orders for
    the purpose of starting manufacturing activities/permitted activities during lockdown
    period in above mentioned factory/establishment. I also affirm and certify that we have
    strictly follow the Standard Operating Protocol as laid down by the Ministry of Home
    Affairs, GoI as well as Ministry and advisories issued from time to time in this regard.

    I also undertake that I will permit the officers of the State Government or its agencies at all
    reasonable hours to enter into and upon the premises for inspection related to comply with
    the norms of modified lockdown.

    Certified that the particulars given above are true and correct to the best of my knowledge
    and in accordance with our record. I understand that any concealment or furnishing any
    false information shall amounts to initiate legal action against me and other responsible
    persons of the Management of the applicant firm or company in accordance with the
    provisions of Section 51 to 60 of the Disaster Management Act, 2005 read with Section
    188 of the Indian Penal Code.

    Place: Signature of Executor


    Date: Name in Block Letters
    Photo ID No.
    Official Seal

    Note: Any false information shall cause to the competent authority to cease the factory
    premises/establishment and legal action shall be initiated against the responsible
    persons in accordance with prevailing laws.
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