Form XIV

[Under Rule-43 (3)]

PROFORMA OF LICENSE

Licence No. ------------- Reg. No. ----------- Date of Reg. ----------

Licence is hereby granted to --------------------------------------------------------------------

for the premises known as --------------------------------------------------------------------

situated at -----------------------------------------------------------------------------------

for use as a establishment within the limits stated herein after, subject to provisions of the

Occupational Safety, Health and Working Conditions Code, 2020, and the rules made there under.

The ------------ 20.. Issuing Authority

Sl.No. Period of Valid For Fee Date of Excess Date of Signature

issue Maximum Payment fee for payment of the

number of late Issuing

Contract payment Authority

labour

/workers on

any one day

AMENDMENTS:

Year when Maximum Date of payment Date of Payment Signature of the

Amended number of of Issuing

Contract labour amendment fee Authority

/workers on any

one day