Form 1

(see rule 5(1)(a), 5(6) & 6(1))

Application for Registration for existing establishment or factory/New Establishment or

factory/Amendment to certificate of Registration

A. Establishment Details

1. Retrieve details of Establishment through LIN:

2. Name of Establishment:

3. Location and Address of the Establishment:

4. PAN:

5. Other 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(a). For Factories:

Details of the Full postal address Name and address Maximum Maximum

manufacturing and situation of the of the occupier and number of Power

process factory along with manager workers to be installed/used

plan approval details employed on

any day

1 2 3 4 5

5(b). For Beedi and Cigar Works:

Details of the Full postal Name and Maximum Number of

manufacturing address and address of the number of home workers

process situation of the employer and workers to be

establishment manager employed on

any day in the

establishment

1 2 3 4 5

5(c). For Motor Transport undertaking:

Nature of motor Full postal Name and Maximum Total No. of

transport service e.g. address and address of the number of Motor

situation of the employer and workers to be transport

City service, long

establishment manager employed or vehicles

distance passenger

proposed to be

service and long on the date of

employed during

distance freight service

‍609

etc. period of application

registration

1 2 3 4 5

5(d). For building and other construction work:

Type of Probable period of Expected period Details of Date of

Construction commencement of for completion of approval of the Commencement

work work work local authority /Probable date

of Completion

of work

1 2 3 4 5

5(e). For News Paper Establishments:

Name of Full postal Name and address Maximum number Date of

Establishment address and of the employer of workers to be Commencem

s situation of the and manager employed on any ent /Probable

establishment day in the date of

establishment Completion

of work

1 2 3 4 5

5(f). For Audio-Visual Workers:

Name of Full postal Name and address Maximum number Date of

Establishment address and of the employer of workers to be Commencem

s situation of the and manager employed on any ent /Probable

establishment day in the date of

establishment Completion

of work

1 2 3 4 5

6. Ownership Type/Sector:

7. Activity as per National Industrial Classification:

8. Details of Selected NIC Code:

9. 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/ port authority etc.:

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. Contractor Details

Name and Email address & Name of Work Maximum No. of Date of

Address Mobile of Contract labour Commencement

Contractor Contractor engaged /Probable date

of Completion of

work

1 2 3 4 5

E. Others Details:

Signature/ E-sign/digital sign of Occupier/Employer

Dated:

Place:

Declaration by the Occupier/Employer for Auto-Registration of Factory

I hereby declare that the information furnished above, including the address of the factory, is true

and correct to the best of my knowledge and belief. I further declare that I have ensured that the

use of the above-mentioned premises is duly approved for the purpose of carrying out the

manufacturing process specified in column (1) of the Table under clause 5(a) of Form-1.

Signature/ E-sign/digital sign of Occupier/Employer

Name:

Designation:

Date:

Place: