Form XVII

[See Rules 60]

Application for grant or renewal of licence for Bidi & Cigar Establishment

1. Registration No. of Establishment as per Section 3 of OSH code .........

2. Full name of the industrial premises-

3. (i) Full postal address and situation of the industrial premises.

(ii) Full address to which communication relating to the industrial premises should be sent.

(iii) Full address of the applicant.

4. Maximum number of employees proposed to be employed on any one day during the

financial year.

5. Full name and residential address of employer -

6. If the employer is a partnership, company, etc. full name and residential address of other

partners or directors, etc. (* Note 1).

7. Financial resources of the employer (e.g., particulars and value of movable and immovable

properties, bank reference, income-tax assessment, etc.).

8. Whether the employer is a trade mark-holder registered under the Trade and Merchandise

Marks Act, 1958.

9. Value of beedis or cigar or both manufactured at the industrial premises during the preceding

financial year.

10. Previous experience of the applicant* in the industry.

11. Whether the proposed site of the industrial premises amounts to the alteration of the site of

any existing industrial premises and, if so, the reasons for such alteration.

12. Whether any industrial premises was closed by the applicant during the period of twelve

months immediately preceding the date of the application, and if so, the reasons therefor.

13. Source of obtaining tobacco.

14. Whether the beedis or cigars or both manufactured by the applicant* will be sold and

marketed by himself or through a proprietor or a registered user of a trade mark registered

under the Trade and Merchandise Marks Act, 1958, or any other person.*

15. Whether the plans of the premises are enclosed.

I hereby declare that the particulars furnished by me in the form are to the best of my

knowledge and belief accurate.

Signature of applicant.

Note 1. - Where an industrial premises is run or proposed to be run by a contractor for or on

behalf of another person or persons or company, etc., the said other person or persons or company,

etc., is under the Act the employer and particulars to be entered for "employer" in the Form should

be in regard to such person, persons or company, etc.

*The application for licence may however be made either by the contractor or the employer.

(2) If any person named against item 5 shall not be minor.