FORM ‘A’

[See Rule 3]
Muster-roll

1 Name and Address of the Establishment AstraZeneca India Private Limited

1 10th & 11th Floors, Neville Tower,Ramanujam IT City
1 A (SEZ), TaramaniRajiv Gandhi Salai ( OMR ),
1 B Chennai 600113, India.
1 C
D

2 Name of the Employee NIL

3 Date of appointment NIL
4 Nature of work NIL
5 Dates with month and year in which she is employed, laid off and not re-employed:
Month        No. of days employed No. of days laid off No. of days not employed

NIL NIL NIL NIL

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
12 Date with the amount of maternity benefit paid in advance of expected 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
15 Date with the amount of wages paid on account of leave under Section 9 NIL
16 Date with the amount of wages paid on account of leave under Section 10 and period NIL
17 of leaveofgranted
 Name the person nominated by the woman under Section 6 NIL
18  If the woman dies, the date of her death, the name of the person to whom maternity NIL
19 benefit
 If and/ordies
the woman other amount
and wassurvives,
the child paid, thethe
amount
name thereof and thetodate
of the person whomof payment
the NIL
20 amount ofof
Signature maternity benefit
the employer of was paid on behalfauthenticating
the establishment of the child and
thethe period
entries in for
thewhich
muster-
21 roll
 Remarks column for the use of the Inspector NIL

Date : Authorised Signatory

1
 AstraZeneca India Private Limited
11th Floors, Neville Tower,Ramanujam IT City
EZ), TaramaniRajiv Gandhi Salai ( OMR ),
Chennai 600113, India.

NIL
NIL
NIL

Total Days Employed

NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL

NIL

rised Signatory