Form 34

{See sub-rule (1) of rule 103 and Rule 105}

Application for grant/ renewal of licence for Beedi and Cigar Work

1. Full name of the industrial premises………………………………………..

2. (i) Full postal address and situation of the industrial premises. .............................................

(ii) Full address to which communication relating to the industrial premises should be sent……….

(iii) Full address of the applicant.*…………………………………………………………………

3. Maximum number of employees proposed to be employed on any one day during the financial year.

……………………………………………………………………………………………..

4. Full name and residential address of the person who shall be the employer for the purposes of the

Code . ……………………………………………………………………………………………..

5. If the employer is a partnership company, full name and residential address of other partners or

directors. (see Note at the end)………………………………………………………………………

6. Financial resources of the employer e.g., particulars and value of movable and immovable properties,

bank reference, income-tax assessment. ………………………………………………….

7. Whether the employer is a trade mark holder registered under the Trade and Merchandise Marks Act,

1958. …………………………………………………………………………………………….

8. Whether the proposed site of the industrial premises amounts to the alteration of the site of any

existing industrial premises and, if so, the reasons for such alteration. ……………………………..

9. Source of obtaining tobacco. ………………………………………………………………………

10.Whether the beedis or cigars or both manufactured by the applicant* will be sold and marketed by

himself or through a proprietor or a registered user of a trade mark registered under the Trade and

Merchandise Marks Act, 1958, or any other person. …………………………………………………

11. Whether the plans of the premises are enclosed. (Yes/No)

12. Amount of fee Rs. ………………………………

I Hereby declare that the particulars furnished by me in the form are to the best of my knowledge and

belief accurate

Date

Signature of applicant*

Note .- Where an industrial premises are run or proposed to be run by a contractor for or on behalf of

another person or persons or company, the said other person or persons or company is under the Act the

employer and particulars to be entered for “employer” in the Form should be in regard to such person,

persons or company.

*The applicant for licence may, however, be either the contractor or the employer.