Form 3

{See clause (a) of sub-rule (1) of Rule-5}

Application for Registration for existing establishments/ New Establishment/ Amendment to certificate of

Registration

A. Establishment Details.

1. LIN Number (if already registered to retrieve details of Establishment from Portal) :

2. Name of Establishment:

3. Location and Address of the Establishment:

4. Others details of Establishment:

a. Total Number of employees and workers engaged directly or indirectly in the

establishment:……………………………………

b. Total Number of the contract employees and workers engaged:

……………………………………………………

c. Maximum number of Contract employees engaged or to be engaged in

process:…………………………………………….

d. Total Number of Inter-State Migrant workers

employed:……………………………………………..

5. Type of Establishment relating to................. (a). Factory (b). Plantation (c). Motor

transport undertaking (d). Beedi and cigar workers (e). Building or other Construction

work

(f). Audio-visual production (g). Other Establishment

6. (a) For factories:

Details of the Full postal address and Name and Maximum Name of the

manufacturing situation of the address of the number of workers chemicals to be

process factory along with occupier and to be employed on handled and stored

plan approval details manager any day along with quantity

1 2 3 4 5

6. (b) For plantation:

Total area of Full name and Name and address Maximum Name of the hazardous

plantation in residential address(es) of the employer number of chemicals, insecticides,

hectares of the directors (in workers to be pesticides to be handled and

case of a company) employed stored along with quantity

1 2 3 4 5

6. (c) For motor transport undertaking:

Nature of Total Total route Total Maximum Name and Full name

motor number mileage number of number of address of and

transport of routes transport motor the residential

service e.g. vehicles on transport employer address(es)

city service, the last date workers of the

long-distance of the employed on directors (in

passenger preceding any day case of a

service, long- year during the company)

distance preceding year

freight service

1 2 3 4 5 6 7

6 (d) For Beedi and Cigar Work:

Financial resources Whether the Previous Value of beedis Whether the

of employer e.g. employer is a experience and cigars, or both, proposed site of

(particulars and trademark holder of the manufactured at industrial premises

value of movable registered under the employer in the industrial amounts to the

and immovable Trade and the industry premises during the alteration of the site

properties, bank Merchandise Marks preceding financial of any existing

references, income Act, 1958 year industrial premises

tax assessment etc.) and if so reasons for

such alterations.

1 2 3 4 5

Whether any Source of Whether the beedis or cigar, or Full name and Maximum

industrial premises obtaining both, manufactured by the residential number of

was closed by the tobacco applicant will be sold and address(es) of employees to

applicant during the marketed by himself or the Directors (in be employed

period of twelve through the proprietor or a case of a on any day

months immediately registered user of the company)

preceding the date of trademark registered under the

the application and, Trade and Merchandise Marks

if so, reasons Act, 1958 or any other person

therefore

6 7 8 9 10

6.(e) For building and other construction work:

Type of Probable period of Expected period for Details of approval of the

Construction commencement of completion of work local authority

work work

1 2 3 4

6.(f) for audio-visual production:

Name and address of the Producer/ Producers of the Maximum number of audio-visual workers to

production house be employed on any day

1 2

6.(g). Other Establishment)

Details of Full postal address and Name and Maximum Name of the

the industry, situation of the address of the number of workers chemicals to be

trade, business factory along with occupier and to be employed on handled and stored

or occupation plan approval details manager any day along with quantity

1 2 3 4 5

7. (a) for registration of principal employer under Part-I of Chapter XI:

1 The name and location of the establishment

2 Postal address of the establishment

3 Full name and address of the Principal Employer (furnish father’s name in the case of individuals)

4 Full name and addresses of the manager or the person responsible for the supervision and control of

the establishment

5 Nature of work carried on in the establishment

6 Particulars of contractors and contract labour:

(a) Names and addresses of contractors

(b) Nature of work in which contract labour is employed

(c) The maximum number of contract labour to be employed on any day through each contractor

(d) Estimated date of commencement of each contract work under each contractor

(e) Estimated date of termination of employment of contract labour under the contractor

(f) Particular is of fees deposited

I hear by declare that the particulars given above are true to the best of my knowledge and belief.

Principal employer

7.(b)For Contract work:

Name and Email address& Name and Maximum No. of Date of Commencement

Address Mobile of Contractor nature of Contract labour / Probable date of

Contractor Work engaged Completion of work

1 2 3 4 5

7.(c)The details of Inter-state migrants employed /to be employed in an establishment:

S.No. Name Father’s/ Permanent address Aadhar Mobile

Husband’s name Number Number

Town/ village Tehsil Distric State

t

7. Ownership Type/Sector:

8. Activity as per National Industrial Classification:

9. Details of Selected NIC Code:

10. Date of opening/Start of business:

11. Identification of the establishment: e-sign/ digital sign of employer/ representative:

12. Details of Employer:-

a. Name & Address of Employer / Occupier / Owner/Agent:

b. Designation:

c. Father‘s/ Husband‘s Name of the Employer:

d. Email Address, Telephone& Mobile No:

13. Manager/ Agent Details

a. Full name & Address of Manager/ Agent or person responsible

for supervision and control of the Establishment

b. Address of Manager/Agent:

c. Email Address, Telephone& Mobile No :

14. Other details:

Date: Signature/ e-sign/

digital

Place: signature of employer

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