SURAT MUNICIPAL CORPORATION
Gujarat Shops and Establishments (Regulation of Employment and
Condition of Service) Act, 2019
Form-D
(See rule 6)
FORMAT FOR INTIMATION
Photo
Application No. : 2021070500064
1 Name of the Establishment :-
SHREE JAY JALARAM AUTO
2 Previous details of establishment :- WZ/S/ADAJAN/144596
Registration No.
3 Date of Expiry :-
4 Postal address and situation of
:-
the Establishment
SHOP NO 11 DIZNEY HOUSE APPARTMENT NEAR
NAVYUG COLLEGE RANDER ROAD RANDER ROAD
SURAT 395009
17-B-13-1401-0-1
5 Date of Commencement of Business :- 28/09/1984
6 Nature of Business Whether :- Public/Private
establishment falls under Public
Sector or Private Sector
TWO WHEELER REPARING
7 Total No. of Employee Men: 0 Women: 0
:-
Total: 0
8 Name of the Employer :-
JITENKUMAR PRAVINBHAI CHAUHAN
Age: 33
Residential Address of the Employer :-
SHOP NO 11 DIZNEY HOUSE APPARTMENT NEAR
NAVYUG COLLEGE RANDER ROAD
Status/Designation :-
Mobile No. and e-mail ID :-
9 Name, Address, Mobile No. and
:-
E-mail ID of the Manager(if any)
10 (a) Category of Establishment :- SHOP
i.e. Shop/ Establishment
(b)Type of organization i.e. :- Proprietor
Proprietor, Partnership, LLP,
Company/ Trust/Co-operative
Society/Board
11 Name of the members of employer's :- Name of the person Relation
family employed in the establishment
Self-Declaration
I/ We hereby solemnly affirm and state that the business which I/ we have started is not banned or
prohibited by any labour laws, Rules or Order of any labour Court or any competent authority under
labour laws and the premises where I/ we are conducting the said business is free from violation of any
labour laws, Rules, Order of any labour Court or any Competent Authority under labour laws.
I/ We hereby declare that the information provided above is true and correct to the best of my
personal knowledge, information and belief. I am fully aware about the consequences of giving false
information. If the information is found to be false, I shall be liable for prosecution and punishment under
the Indian Penal Code (45 of 1860) and/ or any other law applicable thereto.
I/ We have obtained necessary under labour laws related licenses, permissions, permit for the
conduct of this business and the place of business from the appropriate Authority.
I/We shall be responsible and liable for legal action if the business is conducted without proper
labour laws related license, permission, permit from the appropriate Authority.
I/ We hereby declare that the copies attested by me are true copies of original documents. I am well
aware of the fact that if the copies are found false/ forged, I shall be liable for prosecution and
punishment under the Indian Penal Code (45 of 1860) and/ or any other law applicable thereto.
I/ We undertake to abide by the provisions of the Gujarat Shops and Establishments (Regulation of
Employment and Condition of Service) Act, 2019 (Guj. 4 of 2019) and the Rules and orders passed
thereunder by any Authority.
Date: 05-07-2021
Place: Surat
Name and Signature of Applicant