Form I

(See rule 3(1))

Application for registration of establishment/Amendment to certificate of registration/ Updation of registration particulars of

establishments already registered under any other Central Labour Laws

A. Establishment Details.

1. Retrieve details of Establishment through LIN:

2. Name of Establishment:

3. Location and Address of the Establishment:

3 a. PAN:

4. Others details of Establishment:

a. Total Number of employees engaged directly in the establishment:

b. Total Number of the contract employees engaged:

c. Total Number of Inter-State Migrant workers employed:

5 (a) For factories:

Details of the Full postal Name and Maximum number

manufacturing address and address of of

process situation of the the occupier workers to be

factory and manager employed on any day

1 2 3 4

5 (b) For mines:

Name of Lease extent of Name and Average Maximum

Mineral(s) the mine (in address of the Monthly number of

Acres) owner output, persons to be

targeted employed on any

(Tonne) day

1 2 3 4 5

5 (c) For Dock work:

Name of dock Types of Dock Name of the Name of the Name of the

Work/Major Works Cargo handled chemicals hazardous

Port and stored handled and Chemicals

along with stored along handled and

quantity with quantity stored along

with quantity

1 2 3 4 5

5 (d) For building or other construction work:

Type of Probable period Expected Details of

Construction of period for approval of

work commencement completion of the local

of work work authority

1 2 3 4

5 (e) Any Other establishment:

6. Ownership Type/Sector:

7. Activity as per National Industrial Classification:

8. Details of Selected NIC Code:

9. Identification of the establishment e-sign/ digital sign of employer/ representative:

B. Details of Employer:-

1. Name & Address of Employer / Occupier / Owner/Agent/ Chief Executive/ port authority etc. :

2. Designation :

3. Father’s/ Husband’s Name of the Employer :

4. Email Address, Telephone& Mobile No. :

C. Manager/ Agent Details:-

1. Full name & Address of Manager/ Agent or person responsible for supervision and control of the Establishment

2. Address of Manager/ Agent:

3. Email Address, Telephone& Mobile No. :

D. Contractor Details:-

Name and Email address & Name of Work Maximum No. of Date of

Address of Mobile No. of Contract labour Commencement

Contractor Contractor engaged /Probable date of

Completion of

work

1 2 3 4 5

E. Others Details:-

Signature/ E-sign/digital sign of employer

Dated:-

Place:-