Form 25

{See sub-rule (1) of rule 78}

Application for Licence/ Renewal of Licence/Amendment of Licence

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 :

II. Details of Employer:

1. Full Name of Employer:

2. relationship with establishment.

3. Full Address of Employer:

4. Email Id of employer:

5. Mobile No. of employer:

III. Details of contractor applying for licence:

1. Name and address of the contractor (including his father's name in case of individuals)

………………….

2. Date of birth and age (in case of individuals) ………………….

3. Number and date of certificate of registration of the establishment under the

code……………………….

4. Name and address of the principal employer …………………..

5. Particulars of contract labour:

(a) nature of work in which contract labour is employed or is to be employed in the

establishment ……………..

(b) duration of the proposed contract work (give particulars of proposed date of

commencing and ending) ……………………..

(c) name and address of the agent or manager or contractor at the work site …………….

(d) maximum number of contract labour proposed to be implied in the establishment on

any day

6. Maximum number of Inter-state migrant worker proposed to be employed on the

Establishment on any date ……………………….

7. Whether the contractor was convicted of any offence within the proceeding five years, if so,

give details ………………………………………………………

8. Whether there was any order against the contractor revoking or suspending licence or

forfeiting security deposits in the respect of an earlier contract, if so, the date of such order

……………………………………………

9. Whether the contractor has worked in any other establishment we didn't past 5 years if so

give details of the principal employer establishment and nature of work whether certificate

by the principal employer in Form- 26 is enclosed ……………………

10. Amount of licence fee paid ……………………

11. Amount of security deposited ……………………..

Declaration: I, ………………………………………… hereby declare that the details given

above are correct to the best of my knowledge and belief.

Place: Signature of applicant

Date:

APPLICATION FOR AMENDMENT OF LICENCE

1. Licence No:

2. Date:

3. LIN & PAN

4. Name and address of the establishment:

5. Name and address of the contractor:

6. 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) Maximum number of Inter-state migrant worker proposed to be employed on the

Establishment on any date ……………………….

(c) Details of fees paid through e payment date on which made :

(d) Other details requiring amendment in the licence issued (Necessary documents may be

uploaded in support of change required)

Declaration: I, ………………………………………… hereby declare that the details given above

are correct to the best of my knowledge and belief.

Date of Application: Signature of the Contractor