Section 168 · Form-I

Application for Registration of Existing Establishment/New Establishment/Amendment to Registration Certificate (See Rule 3)
A. Particulars of Establishment
1. Locating details of establishment through LIN:
2. Name of the Institution:
3. Location and address of the establishment:
4. Other particulars of the establishment:
A. Total number of employees directly employed in the establishment:
B. Total number of contract employees employed:
C. Total number of inter-state migrant workers employed:
5 (a) For factories:
1. Description of manufacturing process - 2. Complete postal address and location of the factory with details of plan approval - 3. Name and address of the occupier and manager - 4. Maximum number of workers to be employed on any given day
5 (b) For mines:
1. Name of minerals - 2. Lease limit of mines (in acres) - 3. Name and address of the owner - 4. Target average monthly production (tonnes) - 5. Number of workers to be employed on any given day Maximum number of persons
5 (c) For Dock Works:
1. Name of Dock Works/Main Port - 2. Type of Dock Works - 3. Name of Cargo to be Handled and Stored, including Quantity - 4. Name of Chemicals to be Handled and Stored, including Quantity - 5. Name of Hazardous Chemicals to be Handled and Stored, including Quantity
5 (d) For Building and Other Construction Works:
1. Type of Construction Work - 2. Expected Start Time - 3. Expected Completion Time - 4. Details of Local Authority Approval
6. Ownership Type/Sector:
7. Activity as per National Industrial Classification:
8. Details of Selected NIC Code:
9. Identification of Establishment, E-Signature/Digital Signature of Employer/Representative:
b. Employer Details:
1. Name and Address of Employer/Occupier/Owner/Agent/Chief Executive/Port Authority, etc.:
2. Designation:
3. Name of Father/Husband of Commissioner:
4. Email Address, Telephone and Mobile Number:
c. Manager/Agent Details
1. Full name and address of the manager/agent or person responsible for the supervision and control of the establishment.
2. Manager/Agent's address:
3. Email address, telephone and mobile number:
d. Contractor Tax Details
1. Contractor's name and address - 2. Contractor's email address and mobile number - 3. Title of the work - 4. Maximum number of contract workers employed - 5. Expected start/completion date of the work.
e. Other Details:
Employer's Signature/E-Signature/Digital Signature
Date:
Place: