Department of Labour and Employment FORM 21 (Prescribed under sub rule (3) of rule 110) LEAVE WITH WAGES - ANNUAL RETURN For the year ending 31st December 200 Name of the Factory _ Name of the Occupier _ Name of the manager _ District _ Postal Address _ Nature of Industry _ Total number of persons employed during the year Men _ Women _ Children _ Number of Persons who were entitled to _ annual leave with wages during the calendar year to which this return relates Men _ Women _ Children ` _ Number of persons who were granted _ leave during the year Men _ Women _ Children _ Number of persons who gave notice not _ to avail themselves of leaves during the year in which leave accrued - Men _ Women _ Children _ Number of workers discharges from service _ During the year Number of discharged workers paid wages _ In lieu of leave Certified that the information furnished above is correct to the best of knowledge and belief. Date: Signature of Manager
