:::Labour Department:::

छत्तीसगढ़ शासन श्रम विभाग

e-श्रमिक सेवा

होम

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असंगठित कर्मकार मंडल

श्रम कल्याण मंडल

राज्य कर्मचारी बीमा सेवाए

औद्योगिक न्यायलय

इज ऑफ़ डूइंग बिज़नेस

Form No.I
(See Rule 3,4,5)
Application for grant of licence under Beedi and Cigar workers (Condisions of employment) Act 1966 for the finacial year
commencing on 1st April

		* Office
		*

* 1.Full Name of the industrial premises

2(I)Full postal address and situation of the Industrial Premises

Name of Building

Street

Landmark

Locality / Ward

State

District

Block

Village

PinCode

Mobile No.

* *

Email-Id

Fax No

Landline No

2(ii)Full address to which communications relating to the industrial premises should be sent
(Same As Above)

Name of Building

Street

Landmark

Locality / Ward

State

District

Block

Village

PinCode

Mobile No.

* *

Email-Id

Fax No

Landline No

2(iii)Full Name Of Applicant

Name Of Applicant	Date of Birth

Full Address of Applicant

Name of Building

Street

Landmark

Locality / Ward

State

District

Block

Village

PinCode

Mobile No.

* *

Email-Id

Fax No

Landline No

3. Maximum Number of Employees proposed to be employed on any one day during the Financial year commencing on

Establishment using power run machineries

Establishment using no power run machineries

Males

Females

Transgender

Total

E-Challan No

Fee

4.Full Name of the person who shall be the employer for the Purpose of the Act.

Residential address of the person who shall be the employer for the Purpose of the Act.

5.If the employer is a company within the meaning of the Explaination to Section 34,state the full Name of Director,partner,the person incharge of ,and responsible to the Company.(See Note 1 at the end)

YES

6.Financial resources of employer,e.g.particulars and value of movable and inmovable properties,banks refernce,income tax assessment

1.Value of movable and immovable properties	2.Bank Name
*	*
3. Income Tax assessment	4.Other
*	*
Account Number
*

7.Whether the employer is a trademark holder registered under the Trade and Merchandise Marks Act,1958

YES

8.Values of bidis or cigar or Both Manufactured at Industrial Premises during the preceeding financial year

9.Previous Experience of the applicant in the industry(In Years)

10.Whether the proposed site of industrial premises amounts to the alteration of the site,of any existing industrial premises and if so,the reason for such alteration

YES

11.Whether any industrial Premises was closed by the applicant during the period of twelve months immediately proceeding the date of the application,and,ifso,the reason therefor

YES

12.Source of obtaining Tobacco

13.Whether the Bidis or cigars or Both Manufactured by the Applicant will be sold and marketed by himself orthrough a proprietor or a registered user of Trade mark registered under the Trade and Merchandise Mark Act,1958,or any other person

14.Whether the plans of the premises are enclosed.

YES

Self Declaration

I, Mr./Mrs./Ms. Age hereby declare that the above particulars furnished by me are to the best of any knowledge and belief accurate

I Agree

Note:
1)Whether an industrial premises is run or proposed to be run by a contractor for or on behalf of another person including company aforesaid the said other person or company is under the Act the employer and particulars to be entered for "employer" in the Form should be in regard to such person.
2)(i)If any person named against item 5 is a minor,the fact shall be started clearly.

Kindly recheck the filled information before submitting the form / application, as you will not be able to change it later.