Form XXII

(See rule 89(1) and rule 90(2))

PROFORMA OF LICENCE

Licence No. ------------- Reg. No. ----------- Date of Reg. ----------

Licence is hereby granted to --------------------------------------------------------------------

for the premises known as --------------------------------------------------------------------

situated at -----------------------------------------------------------------------------------

nature of work__________

for use as a establishment within the limits stated herein after, subject to provisions of the Occupational Safety, Health and Working Conditions Code, 2020, and the

rules made there under.

The ------------ 20.. Issuing Authority

Sl.No. P eriod of issue Valid For

Excess Signature

Maximum Date of fee for Date of of the

number of Fee Payment late payment Issuing

Contract labour payment Authority

on any one day

AMENDMENTS:

Year when Maximum Date of payment of Date of Signature of

Amended number of Contract labour on any one day amendment fee Payment the Issuing

Authority

E-sign /digital sign of the designated authority