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FORM - V

[See Rule 7 (2)]

Application for licence for employment

1.

Name and address of the contractor (including his Father's / Husband's Name in case of individuals)

 

2.

Date of birth and age (in case of individuals)

 

3.

Particulars of establishment where migrant workmen are to be employed :

 

 

(a) Name and address of the establishment

 

 

(b) Type of business, trade, industry, manufacture or occupation, which is carried on in the establishment

 

 

(c) Number and date of certificate of registration of the establishment under the Act

 

 

(d) Name and address of the principal employer

 

4.

Particulars of migrant workmen :

 

 

(a) Nature of work in which migrant workmen are employed or are to be employed in the establishment

 

 

(b) Duration of the proposed contract work (give particulars of proposed date of commencing and ending)

 

 

(c) Name and address of the agent or manager of the contractor at the work site

 

 

(d) Maximum number of migrant workmen proposed to be employed in the establishment on any date

 

 

(e) Names and addresses of the directors / partners (in case of companies and firms)

 

 

(f) Name (s) and address(es) of the person(s) in-chare of and responsible to the company / firm for the conduct of the business of the company / firm, as the case may be :

 

5.

Whether the contractor was convicted of any offence within the preceding five years?  If so, give details:

 

6.

Whether there was any order against the contractor revoking or suspending licence or for forfeiting security deposits in respect of an earlier  contract?  If so, the date of such order:

 

7.

Whether the contractor has worked in any other establishment within the past five years?  If so, give details of the principal employer, establishment, and nature of work

 

8.

Whether a certificate by the principal employer in Form VI is enclosed?

 

9.

Amount of licence fee paid - No. of crossed demand draft and date :

 

10

Amount of security deposit, if any

 

 

DECLARATION

I hereby declare that the particulars given above are correct to the best of my knowledge and belief.

Place :

Date :

Signature of the Applicant

(Contractor)

Note : The application should be accompanied by a crossed demand draft showing the payment of the prescribed fee and security deposit, if any, and a certificate in Form VI  from the principal employer

... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...

To be filled in the office of the Licensing Officer

 

Date of receipt of Application with Crossed Demand Draft for fees ____________

 Signature of the Licensing Officer

 

 

FORM - VI

[See Rule 7 (3)]

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 Inter-State Migrant Workmen (Regulation of Employment and Condition of Service) Act, 1979 and the Inter-State Migrant Workmen (Regulation of Employment and Conditions of Service) M.P. Rule 1981 in so far as the provisions are applicable to me in respect of the employment of Migrant Workmen by the applicant in my establishment.

Place :

Date :

Signature of Principal Employer

Name and address of Establishment.