Form XXV

PRESCRIBED UNDER RULE 118(3))

FACTORY LICENCE UNDER OSH & WC CODE 2020

1 REGISTRATION NUMBER :

2 FACTORY LICENCE NUMBER : (MUST INDICATE THE YEAR OF

ISSUE OF LICENCE )

3 FULL NAME OF THE FACTORY :

4 FULL ADDRESS / LOCATION :

OF THE FACTORY

5 APPROVED PLAN NUMBER :

6 MANUFACTURING PROCESS / :

LINE OF ACTIVITY /

PRODUCTS MANUFACTURED

7 CLASSIFICATION OF FACTORY : MAH / HAZARDOUS PROCESS /

DANGEROUS OPERATIONS/

OTHERS

8 MAXIMUM HORSE POWER : HP

INSTALLED

9 STANDY POWER GENERATION : KVA

CAPACITY

10 MAXIMUM NUMBER OF :

PERSONS TO BE EMPLOYED

11 FULL NAME, FATHER’S NAME, :

AGE & RESIDENTIAL

ADDRESS OF THE OCCUPIER

AND HIS POSITION IN THE

COMPANY/FIRM/GOVERNMENT

FACTORY/LOCAL FUND

FACTORY

12 I.D PROOF (AADHAR / :

PASSPORT / PAN CARD) OF

OCCUPIER

Licence is hereby granted to the factory at 3 above for the premises

stated at 4 above for use as a factory for carrying out activity at 6 within

the limits stated in 8 and 10 above subject to the provisions of the OSH &

working conditions code 2020 and the rules made there under,

1. This Licence is issued for carrying out manufacturing process /

products mentioned in the Certification of Registration of

Establishment

2. This Licence shall be valid until it has been duly cancelled.

Date: Licensing authority