Form XXII

(See rules 47, 64, 66, 152)

APPLICATION FOR LICENCE

Acknowledgement Number : ------------------ ---------- Date:………………….

Online Application for Licence/ Renewal of Licence/Amendment of Licence

(Including common licence)

I. ESTABLISHMENT PROFILE:

1. Name of Establishment:

2. Labour Identification Number & Date:

3. Address of establishment

a) Head Office address along with Telephone Number & email Id:

b) Corporate office address along with Telephone Number & email Id:

4. Full Name and Address of the applicant:

5. Full Name and Residential Address of the person who shall be the employer for the purpose of the Act:

6. If the employer is a partnership, company etc.,

Full Name and Residential Address of the Partners or Directors etc.,:

7. Activity as per National Industrial Classification: (Select all applicable activities given)

8. Details of selected NIC Code:

9. Nature of work carried on in the main establishment:

10. Identifier of the Establishment :

(Select) :

designation/digital signature

II. Particulars required for Beedi & Cigar Licence

Financial resource Whether the Value of Beedi or Source of Whether beedi or cigars

of the employer employer is a cigars or both obtaining or both manufactured by

(value of movable trademark holder manufactured at tobacco the applicant will be sold

and immovable registered under the industrial and marketed by himself

properties etc.,) the Trade and premises during or through a proprietor or

Merchandise the presiding a registered user of trade

Marks Act, 1968 financial year mark or any other person

1 2 3 4 5

III. Details of Employer:

1. Full Name of Employer: …………………………………………………………………

relationship with establishment.)

2. Full Address of Employer:

3. Email Id of employer:

4. Mobile No. of employer:

IV. Particulars of the Contract labourers to be employed / is employed

(If licence is required work-wise)

Locations Name of Activity as Date of Approximate Name of Establishments

of work works per national commencement Date of in which contract labourers

sites industrial completion is/proposed to be employed

classification

1 2 3 4 5 6

1. Maximum number of workmen proposed to be employed on the Establishment on any date:

2. Amount of Licence Fee: INR (Transaction Id : )

3. Amount of Security Deposit: INR (Transaction Id : )

V. DETAILS OF ESTABLISHMENTS FOR WHICH SINGLE LICENCE IS REQUIRED

Name of State Name Maximum Date of Permanent Permanent Registration

in which the of Each number of commencement establishment establishment number, if

establishments work labourers or probable or probable obtained,

are situated to be/is date of date of then details

employed completion completion there of

Signature of Contractor

(Sign/DSC)

Note: This is an online application.

APPLICATION FOR RENEWAL OF LICENCE

1. Licence No. Date:

2. LIN & PAN

3. Name and address of the establishment:

4. Date of expiry of previous licence:

5. Whether the licence of the employer/contractor was suspended or revoked:

6. Details of Fees paid: (Enclose e-payment receipt): Amount ................. date of payment :

7. E-sign /digital sign of the employer/contractor date:

APPLICATION FOR AMENDMENT OF LICENCE :

1. Licence No Date:

2. LIN & PAN

3. Name and address of the establishment:

4. Purpose and details for which amendment is sought:

(a) Maximum number of workers presently employed: (If there is increase in the maximum number

of workers to be employed, then additional fees/security deposit as per law needs to be deposited:

(b) Details of fees paid through e payment date on which made:

(c) Other details requiring amendment in the licence issued (Necessary documents may be uploaded

in support of change required)

E-sign /digital sign of the employer/contractor date of application.