Form XXVIII

(See rule 72(2), 73, 75(2)

Application for Registration and Grant of Amendment of Licence and notice of Occupation

(To be submitted in triplicate)

1 Application Form Yes/No

a.i.1. Registration, Grant of licence and notice of occupation Yes/No

a.i.2. Amendment of Licence

2 i. Applications name Yes/No

ii. Phone number

iii. i) Whether factory already registered

ii) If yes, Registration number

iii) Licence number

3 Full name and postal address of the factory

a) Panchayath/Municipality/Corporation

b) Village and survey number

c) Taluk

d) District

e) Pin code

4 i. Nearest Police station–distance

ii. Nearest Railway station-distance

iii. Nearest Public Hospital-distance

5 Full name and residential address of the persons who shall be the Manager of

the factory for the purpose of the Act

6 Full name and residential address of the occupier and his designation

eg. Director, Partner, Proprietor or any other (specify) (List of Directors /

Partners should be submitted)

7 Full name and address of the owner of the premises of the building (including

the precincts of thereof) referred Section 93

8 Please furnish the reference number(s) of date(s) of approval(s) of the plans

of the site and building and for disposal of trade wastes and effluents by the

concerned authorities

a.i. State Government

a.ii. Local authority

a. iii. Chief Inspector-cum-Facilitator

a. iv. Pollution Control Board

a. v. Other concerned authority (specify)

9 i. Name of manufacturing process carried out in the factory

ii. In case of application for amendment, indicate manufacturing process

carried out previously

10 The names and quantities of raw materials used, intermediate products and principal finished

products during the last twelve months (in case of factories already in existence) Name Quantity

(Volume/Weight.) 1

1

2

3

11 Number of workers employed in the factory Employed in the last 12 months Proposed to be

employed in the

next 12 months

1. Maximum Number

2. Number ordinarily numbered

12 Nature & total amount of power Installed Proposed to be

(in Kilowatts) installed

13 Previous year’s Labour welfare fund contribution remittance details

(Cheque/DD/Chelan/Cash)

14 Fees paid (Details): Rs ……………………..(in figures) ………….....……….....….…………………..

………………………………………. (in words) vide Treasury Chalan No………………….

Date ………………………………..Drawn on ………...............……………………………

Name and signature of Name and signature of

Manager with date Occupier with date

Notes:

a) The form should be completed in ink in block letters or typed.

b) Strike off whichever is not applicable.

c) If power is not used at the time of filling up this form but introduced later the fact should be

communicated to the Chief Inspector-cum-Facilitator of factories immediately.

d) The term ‘Ordinarily employed’ would mean the total number of workers working in all the shifts

which should be over 50% of the working days in the factory.

e) Head of account 0230-00-104-99

Conditions for Auto renewal.-

I understand that as per provisions of the Code and Rule, if the applicant obtained licence by fraud

or misrepresentation competent authorities can refuse and reject the application and legal action will be

initiated against me

1. I have verified all the data shown to me in Form -XVIII (FORM-G) and undertake that they are all

correct and no deviations from the same and also from the details mentioned in the latest permit issued

to me is existing in my Factory at the time of submission of this application.

2. I undertake that any modifications, additions, extensions to the factory premises, building or machinery

or on any data related to the factory, from the date of submission of this application shall be immediately

brought to the notice of the concerned Inspector through proper means as per Rules and regulations.

3. I undertake that no statutory proceedings initiated by the Department of Factories and Boilers are

pending against me (except for those under the purview of the Honourable Courts) on the date of

submission of this application.

4. I undertake that my Factory complies with all applicable provisions under Code and Rules.

5. I undertake that my Factory possesses all statutory clearances and legal documents as required for

renewal of licence and they are valid at the time of submission of this application and for such extended

renewal period as required.

6. I understand that the Department of Factories and Boilers reserves its right to cancel my auto renewed

licence at any time within its validity period, if any data submitted by me is found to be falsified or if

any data is suppressed from the Department at the time of submission of this application in accordance

with the relevant provisions of the Code and Rules.