FORM IV [See Rule 21(1)] Application for License 1. Name and address of the Contractor (including his father's name in case of individuals). 2. Date of birth and age (in case of individuals). 3. Particulars of establishments where contract Labour is to be employed: (a) Name and address of the establishment. (b) Type of business, trade, industry, manufacture or occupation, which is carried on the establishment (c) Name and date of Certificate of registration of the Establishment under the Act. (d) Name and Address of the Principal Employer. 4. Particulars of Contract Labour: (a) Nature of work in which contract labour is employed or is to be employed in the establishment. (b) Duration of proposed contract work (give particulars of proposed date of commencing and ending) (c) Name and Address of the Agent or manager of Contractor at the work site. (d) Maximum number of contract Labour proposed to be employed in the establishment on any date. 5. Whether the contractor was convicted of any offence with in the proceeding five years? If so, give details: 6. Whether there was any order against the contractor revoking or suspending license or forfeiting security deposits is respect of an Page 54 of 151 earlier contract? If so, the date of such order. 7. Whether the Contractor has worked in any other establishment within the last five years? If so give details of the Principal employer, establishment and nature of work. 8. Whether certificate by the principal employer in Form V is enclosed? 9. Amount of license fee paid - No. of Treasury Challan and Date. 10. Amount of security deposit - Treasury Receipt No. and other. Declarations I hereby declare that the details given above are correct to the best on\f my knowledge and belief. Place: Signature of the Applicant (Contractor). Date: Note - The application should be accompanied by a treasury Receipt for the appropriate amount and a certificate in Form V from the Principal Employer. To be filled in the office of the Licensing Officer. Date of Receipt of the application with Challan for fees/ Security Deposit. Signature of the Licensing Officer Page 55 of 151
