Form XIII

[See rule 21(1)]

Application for Registration of an Establishment under sub-section (3) of Section 57.

A. Establishment Details.

1. Retrieve details of Establishment through LIN/Registration Number:

2. Name of Establishment:

3. Location and Address of the Establishment:

4. 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:

5. Ownership Type/Sector:

6. Activity as per National Industrial Classification (NIC):

7. Details of Selected NIC Code:

8. 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-

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. Details of Approved Gratuity Fund/Insurance obtained for liability of payment

towards the Gratuity;

E. Others Details: -

Date: -Place:

Signature/ E-sign/digital sign of employer