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FORM - IV
[See
Rule 21 (1)]
Application
for Licence
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1.
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Name
and address of the contractor (including his father's name in case
of individuals)
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2.
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Date
of birth and age (in case of individuals)
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3.
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Particulars
of establishment where contract labour is to be employed :
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(a)
Name and address of the Establiment:
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(b)
Type of business, trade, industry, manufacture or occupation which
is carried on in the establishment
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(c)
Number and date of Certificate of Registration of the
establishment under this Act
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(d)
Name and address of the principal employer
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4.
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Particulars
of contract labour -
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(a)
Nature of work in which contract labour is employed or is to be
employed in the establishment
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(b)
Duration of the proposed contract work (give particulars of
proposed date of commencing and ending)
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(c)
Name and address of the Agen6t or Manager of Contractor at the
worksite
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(d)
Maximum number of contract labour proposed to be employed in the
establishment on any date
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5.
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Whether
the contractor was convicted of any offence within the preceding
five years ? If so,
give details:
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6.
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Whether
there was any order against the contractor revoking or suspending
licence or forfeiting security deposits in respect of an earlier
contract. If so, the
date of such order.
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7.
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Whether
the contractor has worked in any other establishment within the
past five years? If
so give details of the principal employer, establishments and
nature of work.
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8.
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Whether
a certificate by the principal employer in Form V is enclosed
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9.
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Amount
of licence fee paid, No. of treasury challan and date
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10
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Particulars
of security deposit, if any, requested to be adjusted, including
treasury number and date.
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The
amount of security or balance, if any after adjustment of amount
to be refunded under Rule 31, if any, deposited with treasury
receipt and date.
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DECLARATION
I hereby declare that the particulars
given above are correct to the best of my knowledge and belief.
Place
:
Date
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Signature of the applicant
(Contractor)
Note
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The application should be accompanied by a treasury receipt for the
appropriate amount and a certificate in Form V from the principal employer
...
... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...
... ... ... ... ... ... ... ... ... ... ... ... ... ... ...
Date
of receipt of Application with Challan for fees / Security Deposit ____________
Signature of the Licensing
Officer
FORM
- V
[See
Rule 12 (1)]
Form
of Certificate by Principal Employer
Certified
that I have engaged the applicant ... ... ... ... ... ... ... ... ... ...
... ... ... ... ... ... ... ... ... ... ... ... ... ... (name of the
contractor) as a contractor
in my establishment. I
undertake to be bound by all the provisions of the Contract Labour
(Regulation and Abolition) Act, 1970 and the Contract Labour (Regulation
and Abolition) Central Rules, 1971, in so far as the provisions are
applicable to me in respect of the employment of contract labour by the
applicant in my establishment.
Place
:
Date
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Signature of Principal Employer
Name and address of
Establishment.
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