Form XXII

(See rule-64(2)(ii)

Application for permission to construct, extend or take into use any building or premises as

a factory

1. Details of Occupier*

(a) Name:

(b) Address (office):

(c) Address (residential):

(d) Mobile number

(e) Email id :

2. Details of factory*

(a) Full name:

(b) Address with pin code:

(c) District: _________________________

(d) Subdivision __________________________

(e) Block

(f) Town / village

(g) Nearest railway Station _____________________________

(h) Nearest Police Station ______________________________

(i) Phone number _______________________________

3. Particulars of plant proposed to be Installed & details of manufacturing process

___________________________

4. Whether the factory involves hazardous processes or dangerous operations – yes or no

5. Maximum number of Workers

Male Female Third Gender

(Proposed To be employed)

6. Details of

(a) Raw material

(b) Intermediate product/by product

(c) Final Product

7. Use of Chemicals in the manufacturing process, if any

S. No. CAS no : Chemical name: Maximum storage at any time:

8. NOTE

a. Seal bearing “ authorized signatory “ shall not be used on any document

b. Every page of the Documents submitted along with the Form should be self attested by the

Occupier along with date.

Place: Date:

Signature of occupier with seal:

(Name)

CHECKLIST

NOTE: This application shall be accompanied by the following documents:-

1. A flow chart of the manufacturing process supplemented by a brief description of the process in

its various stages.

2. Documents related to the ownership of the land:

3. Photo ID and address proof of the Occupier.

4. Declaration regarding occupier of the factory

5. Such other particulars as the Chief Inspector may require.