Form 04

(See Rule-6(1))

Application for Registration for existing establishments/New Establishment/Amendment to

certificate of Registration

A. Establishment Details.

1. Retrieve details of Establishment through LIN:

2. Name of Establishment:

3. Location and Address of the Establishment:

4. Others detail 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:

5 (a) For factories:

Full postal address and situation Name and address Maximum number of

Details of the

of the factory along with plan of the occupier and workers to be

manufacturing process

approval details manager employed on any day

1 2 3 4

5 (c) For Dock work:

Name of the

Name of the

Name of the hazardous

chemicals

Name of dockWork / Types of Dock Cargo handled chemicals

handled and

Major Port Works and stored along handled and

stored along with

with quantity stored along

quantity

with quantity

1 2 3 4 5

5 (d) For building and other construction work:

Details of approval

Type of Construction Probable period of Expected period for

of the local

work commencement of work completion of work

authority

1 2 3 4

6. Ownership Type/Sector:

7. Activity as per National Industrial Classification:

8. Details of Selected NIC Code:

9. Identification of the establishment e-sign/ digital sign of employer/ representative:

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

Date of

Name and Maximum No. of Commencement /

Email address&

Address Name of Work Contract labour Probable date of

Mobile of Contractor

Contractor engaged Completion of

work

1 2 3 4 5

E. Others Details: -

Signature/ E-sign/digital sign of employer

Dated: -

Place: -