Form of Declaration by employer

I/we, hereby declare that the contents given in the application for licence is true and complete

in all respect and I/We fulfill the requirement of the licence as provided in provisions of Occupational

Safety Health and Working Conditions Code, 2020 and Uttar Pradesh rules made thereunder.

I/we further declare that I/We will be fully responsible for any of the particulars given in the

application and if any of the contents found incorrect the licence given to me/us may be withdrawn by

the Authorities under the Code, 2020.

Date:

Place:

Signature

(Name and

Address)