Form XXIII

(See rule-47, 66)

CERTIFICATE OF LICENCE

Licence No. .....................

Reg. No. ......................

Date of Reg. ...................

Licence is hereby granted to …...………………..for the premises known as ….....………situated at……….

for use as a establishment within the limits stated herein after, subject to provisions of the Occupational

Safety, Health and Working Conditions Code, 2020, and the rules made there under.

------------ 20.(date). Issuing Authority

Sl. Period Valid for Fee Date of Excess Date of Name of Full Name and Signature

No. of issue maximum no Payment fee for payment trade mark address of the of the

of Contract late under which registered user Issuing

labourers/ payment beedi/cigar is of the trade authority.

workers on manufactured mark/ or any

any one day other per-son

by whom the

beedi/cigar

mar-keted

1 2 3 4 5 6 7 8 9 10

AMENDMENTS:

Year when Employer Name Maximum number of Date of Date of Signature of

Amended or Address of the Contract labourers / payment of Payment the Issuing

establishment workers on any one day amendment fee Authority

Date Signature of Licencing Authority