The Rajasthan Occupational Safety, Health and Working Conditions Rules, 2026
Form 5
Official text
Open in the official PDF (pp. 172–175)
Tables and forms lose their layout when extracted; the PDF is the authoritative version.
(see rule 6(1), 12, 13(3), 16(2) & 17(2))
Application for License/Renewal of license/Amendment to license/Transfer of license of factory
1. Period of licence:
1. YEAR (s) for which licence is applied for From To
2. General Information:
2a. Full name of the factory
2b. Factory registration number (if RJ -
already registered)
3. Address and contact information of Factory:
3. Full postal address along with pin code and
Contact Number and email id
4. Nature of manufacturing processes:
4a. Date of start of production (for registration)
4b. Manufacturing process carried on in the factory
in the last twelve months
4c. Manufacturing process to be carried on in the
factory during the next twelve months
5. Workers employed:
Male Female Transgender Total
5a. Maximum number of workers
proposed to be employed during the
year
5b. Maximum number of workers
employed during the last twelve
months on any day
5c. Number of workers ordinarily
employed in the factory
615
6. Power installed:
6. Total rated Horse Power or amount of Power
(installed or to be installed or used) whichever
is maximum and K.No. of consumer (attach
sanction load certificate and first electricity bill)
7. Particulars of Factory Manager:
7. Name and address of the person who shall be the Name
Factory Manager (if appointed) of the factory for
the purposes of the Act
Residential
address
Contact No.
and email id
8. Particulars of Occupier:
8a. Name and address of the occupier Name
(in case of a private firm.)
Attach list of partners with complete details,
(in case of partnership firm) Residential
Address
Contact No.
and email id
8b. Name and address of the Director in case of a Name
private/ public limited company
( attach list of Director with details)
Residential
Address
Contact No.
and email id
8c. Full name and residential address of the Name
Managing Agent in case where a managing agent
is appointed by the Central Government Address
/ State Government / Local authority as
Occupier
Contact No.
and email id
9. Land & Building:
9a. Full name and address of the owner of Name
the premises or building (including the
precincts thereof) (referred to in section 93 of Address
the Act)
Contact No.
and email id
9b. Reference number and date of approval of the
plans for site, whether for old or new building
and for construction or extension of factory by
the State Government / Chief Inspector
10. Other information
a. Information of manufacturing process as per National Industrial Classification (NIC Code):
1. Activity as per National Industrial Classification:
2. Details of Selected NIC Code:
b. Identification of the factory:
NOTE:
a. In case of any change in the above information, Department shall be informed in writing.
b. Seal bearing “ authorized signatory “ shall not be used on any document.
Place:
Date:
e-sign/Signature of Factory Manager with seal:
( Name)
e-sign/Signature of occupier with seal:
( Name )
617
VERIFICATION
I, the above named Occupier, do hereby further solemnly affirm that the contents given above
are true to the best of my knowledge.
Place: __________________
Date: __________________
e-sign/Signature of Occupier …………………………….…….