Form XXI

[See rule 87, rule 88(1) and rule 96(1)]

Application for Grant of Licence/ Renewal of Licence/Amendment of Licence (including common/single licence)

Government of India, Ministry of Labour and Employment

ESTABLISHMENT PROFILE:

Labour Identification Number Date

Acknowledgement Number: ………………………………… Date of Application: ………………….

I. Particulars of Establishment for which licence required:

1. Name of Establishment:

2. Address of establishment

(a) Head Office address along with email Id :

(b) Corporate office address along with email Id:

3. Telephone Number :

4. Activity as per National Industrial Classification : (Select all applicable activities given)

5. Details of selected NIC Code:

6. Nature of work carried on in main establishment :

7. Identifier of the Establishment : (Select) : e-sign/digital sign

II. Details of Employer:

1. Full Name of Employer: …………………………………………………relationship with establishment.

2. Full Address of Employer:

3. Email Id of employer:

4. Mobile No. of employer:

III. Particulars of the Contract Labour to be employed / is employed (If licence is required work wise)

Locations of Name of Activity as per Date of Date of Name of Name Address, email id of the Site Incharge

worksites works national industrial commencement completion Establishments

classification in which

contract labour

is/proposed to

be employed

1 2 3 4 5 6

5. Maximum number of workmen proposed to be employed on the establishment on any date:

6. Amount of Licence Fee: INR ( Transaction Id : )

7. Amount of Security Deposit: INR ( Transaction Id : )

IV. DETAILS OF ESTABLISHMENTS FOR WHICH COMMON LICENCE REQUIRED , (IF APPLYING FOR)

Type of Name & Address (i)Nature of work Date of Permanent Maximum

Establishments of establishment carried out in the commenceme establishme number of

establishment (ii) nt nt or contract

Activity as per probable labour

National Ind’l date of employed/

classification completion proposed to

be employed

1 2 3 4 5 6

V. DETAILS OF ESTABLISHMENTS FOR WHICH SINGLE LICENCE IS REQUIRED (IF APPLYING FOR)

Name of Name of each Maximum Date of Permanent establishment or probable Registration number, if obtained, then details

States in work number of commence date of completion thereof

which the labour will be/is ment

establish employed

ments are

situated

1 2 3 4 5 6

Signature of Contractor

(e-Sign/DSC)

Note: This is an online application summary applied on Shram Suvidha Portal or designated Portal.

APPLICATION FOR RENEWAL OF LICENCE

1. Licence No. Date :

2. LIN & PAN

3. Name and address of the establishment:

4. Date of expiry of previous licence :

5. Whether the licence of the employer/contractor was suspended or revoked:

6. Details of fees paid : (Enclose e-payment receipt):

Amount …. Date of payment :

E-sign /digital sign of the employer/contractor date:

APPLICATION FOR AMENDMENT OF LICENCE :

1. Licence No Date:

2. LIN & PAN

3. Name and address of the establishment:

4.Details for which amendment is sought :

(a). Maximum number of contract labour presently employed : When there is an increase in the maximum number of contract labour to be employed, the additional

fee/security deposit required under law shall be deposited:

(b). Details of fees paid through e-payment date on which made :

(c). Other details requiring amendment in the licence issued (Necessary documents may be uploaded in support of change required)

E-sign /digital sign of the employer/contractor

Date of application.

Date:-

Place:-