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FORM X : APPLICATION FOR TEMPORARY LICENCE

[Rule 32 (2)]

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 establishment where contract labor is 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) Name and address of the principal employer.

4. Particulars of contract labor-

(a) Nature of work in which contract labor is 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 Contractor at the work-site.

(d) Maximum number of contract labor proposed to be employed in the establishment on any day.

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 license or forfeiting security deposit in respect of an earlier contract. If so, the date of the 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. 5[Amount of license fee paid name of the Union Bank, demand draft No .and date. ]

9. 5[Amount of security deposit-name of the Union Bank, demand draft No. and date. Date of the receipt of the application with demand draft for fees / security deposits.]

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

Place Signature of the Applicant

Date (Contractor)

(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



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