Form 25

(see rule 65(1), 68(2) & 84)

APPLICATION FOR LICENSE

On Line Application for License/ Renewal of License/Amendment of License (including

Common/single license)

Government of India, Ministry of Labour and Employment

ESTABLISHMENT PROFILE:

Labour Identification Number Date

Acknowledgement Number: ………………………………… Date of Application: ………………….

I. Particulars of Establishment for which licence required:

1. Name of Establishment:

2. Address of establishment

(a) Head Office address along with email Id :

(b) Corporate office address along with email Id:

3. Telephone Number :

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

5. Details of selected NIC Code:

6. Nature of work carried on in main establishment :

7. Identifier of the Establishment : (Select) : esign/digital sign

II. 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:

III. Particulars of the Contract Labour to be employed / is employed (If licence is required work

wise)

Locations of Name of Activity as per Date of Date of Name of Name

worksites works national completion Establishments

commencement Address,

industrial in which contract

email id

classification labour

of the Site

is/proposed to

be employed Incharge

1 2 3 4 5 6

1. Maximum number of workmen proposed to be employed on the Establishment on any date: 24

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

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

IV. DETAILS OF ESTABLISHMENTS FOR WHICH COMMON LICENCE REQUIRED , (IF APPLYING

FOR)

Type of Name & (i)Nature of work Date of Permanent Maximum number of Maximum

Address of carried out in the commencement establishment employees number of

Establishments establishment establishment (ii) or probable employed/ employees

employed/

Activity as per date of proposed to be

National Ind‘l completion employed proposed

classification

to be

employed

1 2 3 4 5 6 7

V. DETAILS OF ESTABLISHMENTS FOR WHICH SINGLE LICENCE IS REQUIRED (IF APPLYING FOR)

Name of Name of Maximum Date of Permanent Maximum Registratio

each work number of establishment number of n number,

States in commenceme if obtained,

labour will or probable employees

which the nt then

be/is date of employed/

establishme

employed completion proposed to details

nts are

be employed thereof

situated

1 2 3 4 5 6 7

Signature of

Contractor

(eSign/DSC)

Note: This is an online application summary applied on Shram Suvidha Portal.

APPLICATION FOR RENEWAL OF LICENCE

‍643

1. Licence No. Date :

2. LIN & PAN

2. Name and address of the establishment:

3. Date of expiry of previous licence :

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

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

:

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.Details for which amendment is sought :

(a). Maximum number of worker 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 :

©. 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.