Form I

[See Rule-3 (1) (i)]

Application for Registration for existing establishments/ New Establishment/

Amendment to certificate of Registration

A. Type of Establishment.—(Factory/Motor Transport undertaking/Newspaper Establishment/

Audio-Visual Production Establishment / Building and Other Construction Establishment

/Plantation / Contract Work/ Manpower Supply/Other)

B. Establishment Details.

1. Name of Establishment:

2. Location and Address of the Establishment:

3. 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:

4. Fill applicable part-

(a) For factories:

Details of the Full postal Name and Maximum Nature &

manufacturing address and address of number of Total

process situation of the the workers to amount of

factory along occupier be employed H.P. installs

with plan and on any day or propos &

approval details manager installed.

1 2 3 4 5

(b) For Motor Transport Workers-

Nature of motor transport Total number Total route Total number of

services (e.g. City Services, of route mileage transport vehicle

Long distance freight etc) on the last date of

preceding year

1 2 3 4

(c) For building and other construction work:

Type of Construction Probable period of Expected Details of approval

work commencement of period for of

work completion of the local authority

work

1 2 3 4

(d) For Plantation-

Total Full name(s) and Full name and Full name and

grant of residential address(es) residential adress(es) of address(es) of the

plantation of the Propreitor's and the Directors in the Chief Executives or

in hectare Partner's of the case of a Company General Manager

plantation in case it is registered under the of the Plantation in

not registered under Companies Act, 1956. the Public Sector

the Companies Act,

1956

1 2 3 4

5. Ownership Type/Sector;

6. Activity as per National Industrial Classification;

7. Details of Selected NIC Code:

8. e-sign/ digital sign of employer/ representative/applicant :

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 Name Maximum Maximum Date of

Address address& of No. of no. of Commencement /

Contractor Mobile of Work Contract migrant Probable date of

Contractor labour worker Completion of

engaged employed by work

contractor

1 2 3 4 5

E. Others Details:-

Signature/ E-sign/digital sign of employer

Dated:-

Place;-