Form A

(See Rule 3)
Muster-Roll
The Andhra Pradesh Maternity Benefit Rules, 1961

M/s. Connect India E Commerce Services Pvt Ltd,

Name of the Establishment Shutter No-2, Near Penna Bridge Mypadu Road, Nellore-
524002

1 Serial Number NIL

2 Name of woman and her father's (or if married, husband's name) NIL
3 Date of appointment NIL
4 Nature of work NIL
5 Date with month and year in which she is employed, laid off and not re-employed:

No. of days No. of days No. of days

Month employed laid off not employed Remarks
January – 2022 NIL NIL NIL NIL
February – 2022 NIL NIL NIL NIL
March – 2022 NIL NIL NIL NIL
April – 2022 NIL NIL NIL NIL
May – 2022 NIL NIL NIL NIL
June – 2022
July – 2022
August – 2022
September – 2022
October – 2022
November – 2022
December – 2022
6 Date on which the woman gives notice under Section 6 NIL
7 Date of discharge/ dismissal, if any NIL
8 Date of production of proof of pregnancy under Section 6 NIL
9 Date of birth of child NIL
10 Date of production of proof of delivery/ miscarriage/ death NIL
11 Date of production of proof of illness referred to in Section 10 NIL
Date with amount of maternity benefit paid in advance of expected
12 delivery NIL

13 Date with the amount of subsequent payment of maternity benefit NIL

14 Date with the amount of bonus, if paid under Section 8 NIL
Date with the amount of wages paid on account of leave under
15 Section 9 NIL
Date with the amount of wages paid on account of leave under
16 Section 10 and period of leave granted NIL
17 Name of the person nominated by the woman under Section 6 NIL
If the woman dies, the date of her death, the name of the person to
whom maternity benefit and/ or other amount was paid, the amount
18 thereof and the date of payment NIL
If the woman dies, the date of her death, the name of the person to whom
maternity benefits and/ or other amount was paid on behalf of the child and
19 the period for which it was paid. NIL
Signature of the employer of the establishment authenticating the
20 entries in the muster-roll NIL
21 Remarks column for the use of the Inspector. NIL
Date:

Signature of the employer

2022 1 of 1 Connect India - Andhraprasdesh