Name of Factory or Industrial Establishment

Serial No

1 2 3 4 5 6 7 8 9 10

Father's Name or Ticket No.

Department

Date and amount of advance made Purpose (s) for which advance made Number of installments by which advance to be repaid Postponement s granted Date on which total amount repaid

Name Remarks

FORM IV (See Rule 18) Register of advances made to employed persons