Form 54

{See Rule 173}

Application for Common Licence under section 119

Common Application for Licence/ Renewal/ Amendment of Licence applied under Section 119 of the Code

A. Establishment Profile

Name of Establishment

Address of establishment

(a) Head Office address along with e-mail-id

(b) Corporate Office address along with e-mail-id

(c) Location of establishment along with e-mail-id

Contact number(s)

Activity as per NIC (National Industrial Classification) (select all

applicable activities given):

Details of selected NIC code

Nature of work carried on in main establishments

Identifier of establishment: (select – e-sign/ digital sign)

B. Details of Employer

Full name of Employer/ Occupier

Relationship with establishment

Full address of Employer/ Occupier

e-mail id of Employer/ Occupier

Details of all Occupiers/ Partners/ Directors to be furnished along

with **

C. Particulars of the Factory

F Full Activity Date Max. Name of

actory address of as per NIC of power to be used ( establishments in

Name Factory (National applicability KW) which workers to

Industrial as factory be employed

Classification)

1 2 3 4 5 6

Name, Residential address and Mobile no. of Manager/

Factory Manager

Max. no. of workmen proposed to be employed on the

establishment on any date

Amount of Licence fee paid

Transaction id/ proof of deposition

Manufacturing process to be carried out

D. Particulars of the Contract Labour to be employed (if licence is required workwise)

Location of work sites

Nature of work carried out in establishment/ Activity as

per NIC (National Industrial Classification)

Name of establishments where contract labour is proposed

to be employed

Date of commencement

Date of completion

Name, address and -mail of site in-charge

Max. no. of workmen proposed to be employed on the

establishment on any day

Amount of Licence fee paid

Amount of security deposit

Transaction id/ proof of deposition

0

Registration number, if obtained then details they are of

1

E. Details of establishments for which single licence is required (beedi and cigar)

Whether the applicant is a trademark holder registered

under prevailing trade and merchandise market act

Whether the proposed site of the industrial premises

amounts to the alteration of the site of any existing premises and if

so the reasons for such alteration

Whether the beedis or cigars or both manufactured by

applicant will be sold and marketed by himself or through proprietor

or registered user of a prevailing trade and mercantile market act or

any other reason person

Maximum number of labour will be employed at any time

of the day

Date of commencement of work

Plan of the places or premises, the area therein to be used

for manufacturing processes, the immediate surroundings of such

places or premises etc.

Date of application

Signature of employer/ Occupier

Application for Renewal of Licence

Licence number and Date

Registration number

LIN and PAN (for contract labour work only)

NIC code no (as given in the licence)

Name and address of the factory/ establishment

Full address to which communication shall be carried (where the

factory address serves the purpose of communication also, this information

need not to be given)

A flow chart of the manufacturing process supplemented by a brief

description of the process in its various stages, list of the raw material, used

intermediate products including mission of toxic gases, etc., finished products,

their quantities, methods of storage and handling, loading and transport and

details of the arrangement for the disposal of trade waste and effluents (to be

enclosed)

Max. number of workers to be employed on any day during the year

Installed power (in HP)

Details and proof of deposited required fees

0

Date of expiry of previous licence

1

Whether the licence of the employer/ contractor was suspended or

2 revoked

Date of application

Signature of employer/ Occupier

Application for Amendment of Licence

Licence number and Date

LIN and PAN (for contract labour work only)

Name and address of the factory/ establishment

Max. number of workers presently employed

Details for which amendment is sought

Max. number of workers presently employed

a)

Change in number of workers (If the number of workers has to

b) amended and there is an increase in number in the maximum number of

workers to be employed, then additional fees/ security deposit as per rules

needs to be deposited)

Power to be change (in HP)

c)

Change in the name of Occupier or Factory Manager

d)

Change in name of Factory

e)

Nature of manufacturing process to be carried out in the factory (List of

processes)

In case of amendment in manufacturing process, indicate (List of

manufacturing process carried out previously processes)

Details and proof of deposited required fees

Other details, requiring amendment in the licence issued (necessary

documents may be attached/ uploaded in support of change(s) required

Date of application

Signature of employer/ Occupier

** strikeout whichever is not applicable