Form XIII

{See Rule 43(2)}

On Line Application for License/Renewal of License/Amendment/change

of License including Common/single license)

OnLine Application for License/Renewal of License/Amendment of

License(including Common/single license)

Government of Andhra Pradesh,

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 withe-mail Id:

(b). Corporate office address along withe-mail Id:

3.Telephone Number:

4.Activity as per National Industrial Classification:(Select allapplicable 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. Detail 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(licence

is required work wise)

d

t e

e

Lof

o

cations worksites

Nw

aor mk

es

of

Activityasper

national

industrial

classification

Date

of

commencement

Date

of

completion

Name

of

Establishment

i

c

no

n

wtr

hia cc

h

labour

is

propos

te

o

m

bpl

e

oyed

NameAddress,

emailed

oftheSit

Incharge

1 2 3 4 5 6

5.Maximum number of work men 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)

f d f d

o e o e

o

Tf

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pe

Establishments

&

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o

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out

establishment Activityas

per

(ii)I

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onal

classification

Date

of

cm oe

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Permanen

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lish

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ompletio

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employees

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mo pp lo os

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mployed

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axm ib mer

um

ee

mm pp ll oo yy

ees

/

proposed

to

be

employed

1 2 3 4 5 6 7

V.DETAILS OF ESTABLISHMENTS FOR WHICH SINGLE LICENCE IS REQUIRED

(IF APPLYING FOR)

i

oS

Nn

ft aat

me es

t wh he

i

ch

ear

ste

ablishments

situated e o

Nw

fa

ao cr

mhk

e

Maximuml o na f

ubo mu

br

er i /s

b

w

ie

ll

employed

Date

of

commencement

Permanent ee sn tt

ao blr

i

shm pd rat oe

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axm ib

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of

employees employed/ t Pb o

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oposed employed Registration o nb

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1 2 3 4 5 6 7

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 theemployer/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 worker presently employed:(If there is increase in the

maximum number of workers to be employed,then additional fees/security

deposit as per law needs to 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