Form XIII

[Under Rule-32, 33 (1) and 48 (4)]

APPLICATION FOR LICENSE

On Line Application for License/ Renewal of License/Amendment of License (including

Common/single license)

Government of Arunachal Pradesh, Labour and Employment Department

ESTABLISHMENT PROFILE:

Labour Identification Number Date

Acknowledgement Number: ………………………………… Date of Application: ………………….

I. Particulars of Establishment for which license required:

1. Name of Establishment:

2. Address of establishment

(a) Head Office address along with email Id :

(b) Corporate office address along with email Id:

3. Telephone Number :

4. Activity as per National Industrial Classification : (Select all applicable 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. Details of Employer:

1. Full Name of Employer: ...................................................... Designation in establishment.

2. Full Address of Employer:

3. Email Id of employer:

4. Mobile No. of employer:

5. Maximum number of workmen proposed to be employed on the Establishment on any

date:

6. Amount of License Fee: INR (Transaction ID)

7. Amount of Security Deposit: INR (Transaction ID)

III. (a) Particulars of the Contract Labour to be employed / is employed (If license is

required workwise)

Name of

Name

Activity as per Establishments

Locations Address,

Name of national Date of Date of in which contract

of email id of

works industrial commencement completion labour

worksites the Site In-

classification is/proposed to be

charge

employed

1 2 3 4 5 6

III. (b) Particulars of the Beedi & Cigar Work (If license is required workwise)

Whether the

Financial resources proposed site of the

Whether the employer Value of beedi or

of employer e.g. industrial premises

is a trademark holder cigars or both

(particulars and Previous amounts to the

registered under the manufactured at

value of movable experience of alternation of the site

Trade and the industrial

properties, bank the employer of any existing

Merchandise Marks premises during

reference, income in the industry industrial premises

Act, 1958, the details the preceding

tax assessment and, if so, the

thereof financial year

etc.) reasons for such

alternation

1 2 3 4 5

Whether the Maximum number of

Whether any beedis or cigars or Employed to be

industrial both manufactured employed on any

premises was by the applicant day

will be sold and

closed by the

marketed by Full name and (a) Contract

applicant during

himself or through residential Workers

the period of Source of

twelve month obtaining a proprietor or a address (es) of (b) Inter State

immediately tobacco registered user of the Directors in workers

a trade mark case of a

preceding the

registered under Company (c) Other

date of the

the Trade and

application and, if

Merchandise

so, the reasons

Marks Act, 1958,

thereof Total

or any other

person.

6 7 8 9 10

IV. DETAILS OF ESTABLISHMENTS FOR WHICH COMMON LICENCE REQUIRED , (IF

APPLYING FOR)

(i)Nature of work Maximum Maximum

carried out in the Probable number of number of

Type of Name & establishment (ii) Date of date of employees employees

Establishments Address of Activity as per commen- completion employed/ employed/

establishment National cement

Industrial of work proposed to proposed to be

classification be employed employed

1 2 3 4 5 6 7

V. DETAILS OF ESTABLISHMENTS FOR WHICH SINGLE LICENCE IS REQUIRED (IF

APPLYING FOR)

Maximum

Registratio

Name of States Maximum number of

Date of Probable n number, if

in which the Name of number of employees

commencem date of obtained,

establishments each work labour that will employed/

ent completion then details

are situated be/is employed proposed to be

thereof

employed

1 2 3 4 5 6 7

Signature of Contractor

(eSign/DSC)

Note: This is an online application summary applied on Shram Suvidha Portal.

APPLICATION FOR RENEWAL OF LICENCE

1. LicenseNo. Date :

2. LIN & PAN

3. Name and address of the establishment:

4. Date of expiry of previous license :

5. Whether the license of the employer/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. License 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 license issued (Necessary documents may be

uploaded in support of change required)

E-sign / digital sign of the employer / contractor Date of Application.