Form 55

{See sub-rule (3) of Rule 174}

Certificate of Common Licence under Section 119 (2)

Licence No: …………………….

Registration No. ………………….

NIC details: ……………………. Date:

…………………………………..

Licence is hereby granted to ………………………………………. for the premises known as

………………………………. situated at …………………………………………. for use as a Factory/

Establishment within the limits stated hereinafter, subject to provisions of the Section 119 of the

Occupational Safety, Health and Working Conditions Code, 2020 and the Rules made thereunder.

The plan of Factory is approved on ………………… (date) plan number ………………….. by

Director of Factories, UP/ Deputy Director/ Assistant Director of Factories, ……………………………….

having jurisdiction

Date:

Designated

Authority

Details of Licence

Period of Valid for Licence Excess Security Date of

issue Max. no. Max. Fees fees for amount payment

of contract labour/ power used in paid late paid

workers on any one premises (in payment

day HP)

Details of

licence granted

Details of

Renewal

Designated

Authority

Amendments

Date Amendment made Amen Additi

of amendment W Installe Details of dment fees and onal fees (if

orkers d power Other amendments date of any) and date

payment of payment

Designated

Authority