Form I

(See Rule - 5)

Application for Registration for Existing Establishments or New Establishment

And Amendment to Certificate of Registration

A. Establishment Details:

1. Retrieve details of Establishment through LIN:

2. Name of Establishment:

3. Location and Address of the Establishment:

4. Others details of Establishment:

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

b. Total Number of contract workers engaged through contractors:

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

5. Ownership Type/Sector:

6. Activity as per National Industrial Classification:

7. Details of Selected NIC Code:

8. Identification of the establishment (e-sign/ digital sign of employer/representative).

9. (a) For Audio-Visual Production House :

Name and address of the Production House or Maximum number of audio-visual workers to be

the Producers of the Production House employed on any day

1 2

9. (b) For Beedi & Cigar Work:

Value of

Whether the

Financial Whether the beedi or

proposed site of the

Resources of the employer is a cigars or

Previous industrial premises

Employer (e.g. – trademark holder both

experience amounts to

particulars and registered under manufacture

of the alteration of the site

value of movable the Trade and d at the

employer in of any existing

properties, bank Merchandise industrial

the industrial premises

reference, income Marks Act, 1958, premises

industry. and, if so, the

tax assessment If yes, the during the

reasons for such

etc.) registration no. preceding

alterations.

year.

1 2 3 4 5

9. (c) For Building and Other Construction Work:

Probable date of Details of approval of the

Type of Construction Expected period for

commencement of local authority

work completion of work

work (if applicable)

1 2 3 4

9. (d) For Contract Work:

Maximum number of contract labour to be

Name and Address of the Contractor(s)

engaged in any day

1 2

9. (e) For Motor Transport Undertaking:

Maximum

Name of motor

number of

transport service Full name

Total number motor

(e.g. – city and

of transport transport Name and

service, long Total address of

Total Route vehicles on workers address of

distance number of the

Mileage the last day of employed on the

passenger Routes Directors,

the preceding any day employer

service, long in case of a

year during the

distance freight Company

preceding

service etc.)

year

1 2 3 4 5 6 7

9. (f) For Plantations:

Name of the

hazardous

Full name and Maximum

chemicals,

Total area of Name and address of the number of

insecticides,

plantation in address of Directors, in workers to be

pesticides to be

hectares the employer case of a employed on any

handled and stored

Company day

along with its

quantity

1 2 3 4 5

B. Details of Employer:-

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

Contractor Details :

Date of

Name and Email address& Maximum No.

Name of the Commencement and

Address Mobile Number of of Contract

Work the probable date of

Contractor Contractor labour engaged

completion of work

1 2 3 4 5

E. Others Details:-

Signature/ E-sign/digital sign of employer

Dated:-

Place: -