Form 38

{See sub-rule (1) of rule 113}

Application for the work required to be carried out outside the industrial premises

To,

The Additional Chief Secretary/ Principal Secretary,

Labour and Employment,

Government of Uttar Pradesh.

Subject: Application for the work required to be carried out outside the industrial premises

Sir,

I, ………………………………, proprietor/ occupier/ employer of ………………………. (name of

establishment), on behalf of my employees, hereby apply for permission for the work required to be carried

out outside the industrial premises for wetting and cutting of beedi or tobacco leaves.

1. Type of establishment:

2. Name and address of establishment:

3. Licence number:

4. Date of licence:

5. Date of validity of licence:

6. Nature of work:

7. Place or places where the outside work is required to be carried out outside the industrial

premises:

8. Details of suitability of place where outside work of wetting or cutting of beedi or tobacco leaves

is proposed:

9. Brand name/ trademark of product:

10. Source of obtaining beedi or tobacco leaves:

11. Date of commencement of work:

12. Maximum number of employees employed:

13. Remarks:

Declaration:

1. I, hereby declare that all the information furnished by me in the application is true.

2. I abide myself that, if my employees have given this permission, I will ensure that all the

conditions under which this permission will be granted, will be fulfilled by me.

3. I also assure that I will follow all the provisions of the Code and Rules made thereunder and if any

sort of violations are found at any stage, this permission may be withdrawn and action may be

taken against me.

Date: Seal

and signature of

Place: proprietor/

occupier/ employer

or authorized

signatory