Contract Labor (Regulation and Abolition) Act, 1970
FORM IV : APPLICATION FOR LICENCE
[Rule 21 (l)]
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) Number and date of certificate of registration of the establishment under the Act.
(d) Name and address of the Principal Employer.
4. Particulars of contract labor-
(a) Nature of work in which contract labor is employed or 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 date.
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 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, establishments, and nature of work.
8. Whether a certificate by the Principle Employer in Form V is enclosed.
5[9. Amount of license fee-name of the Union Bank, demand draft No. and date.]
10. Amount of security deposit-name of the Union Bank, demand draft No. and date.
Note: The application shall be accompanied by demand draft and the challan for the appropriate amount and a certificate in Form V from the principal employer............ date of the receipt of the application with 'demand draft' and the challan for fees/security deposit.]
I hereby declare that the details given above are correct to the best of my knowledge and belief.
Signature of the Applicant
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