Form 27

(see rule 67(1) & 90(1))

PROFORMA OF LICENSE

Licence No. ------------- Reg. No. ----------- Date of Reg. ---------- Licence is hereby

granted to -------------------------------------------------------------------- for the premises known as --------------------

------------------------------------------------ situated at -----------------------------------------------------------------------

------------nature of work………………………………………….. 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.

The ------------ 20.. Issuing Authority

Sl.No Period of issue Valid For

.

Date of Excess Date of Signatur

Maximum

payment

Fee Payment fee for e of the

number of

Contract late

Issuing

labour

/workers on payment Authority

any one day

1 2 3 4 5 6 7 8

AMENDMENTS:

Year when Maximum Date of payment of Date of Signatur

amendment fee e of the

Amended number of Contract Payment

Issuing

labour /workers on any

Authorit

one day

y

1 2 3 4 5

E-sign /digital sign of the designated authority

‍645