Form I

(See rule-4)

Application for Registration of Establishments /Amendment of Certificate of Registration

A. Establishment Details.

1. Name of Establishment:

2. Location and Address of the Establishment:

3. Others details of Establishment:

a) Total Number of employees directly engaged:

b) Total Number of contract employees engaged:

c) Total Number of Inter-State Migrant workers employed: (details of employees shall be

uploaded in the portal)

4. Type of Establishment ..........(Factory/ Beedi /Plantation/ Construction/other Establishment).

(a) For factories:

Details of Full postal address with PIN and Name and address with Maximum

manufacturing location of the factory along with phone number and number of workers

processes plan and approval details e-mail of the occupier to be employed on

and manager any day

(1) (2) (3) (4)

(b) For building and other construction work:

Type of Probable Date of Expected period for or Details of approval

Construction commencement of work probable date of of the local

work completion of work. authority

1 2 3 4

(c) For Plantations

Name of crops Area in hectare Taluk and village Survey no. and sub

grown divisional no.

1 2 3 4

(d) For Motor Transports undertaking

Nature of motor Total number of Registration number Maximum number of

transport service motor transport vehicles of vehicles workers to be employed on

any day

1 2 3 4

5. Ownership Type & Sector:

6. Activity as per National Industrial Classification:

7. Details of Selected NIC Code:

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

B. Details of Employer:-

a) Name & Address of Employer / Occupier / Owner/Agent/ Chief Executive/ etc:

b) Designation :

c) Father‘s/ Husband‘s Name

d) Email Address, Telephone& Mobile No :

C. Manager/Agent Details:-

a) Full name & Address of Manager/ Agent or person responsible for supervision and control of the

Establishment

b) Address of Manager/ Agent:

c) Email Address, Telephone& Mobile No :

D. Contractor Details

Name and Email address 365 Name of Maximum No. Commencement

Address & Mobile no. Work/Project of Contract labourers Date/ Probable Comple-

Contractor of Contractor engaged tion date of work

1 2 3 4 5

E. Others Details if any :-

Dated:- Signature/E-sign/digital sign of employer

Place;-