छत्तीसगढ़ शासन श्रम विभाग

FORM-IV
[See C.G. Rules 21(1)]
Application For License

Particular's of Contractor's Establishment

Name*

*

Land Mark*

*

Address*

*

State*

*

Dist*

*

Rural/Urban*

*

Block Name*

*

Pin Code*

* *

E.P.F. Registration No*

*

Date of Commencement of Work/Proposed Date *

*

E-Mail ID*

*

If Registered Under Companies ACT*

YES

NO

*

Particulars of contractor in Person

Contractor Name*

*

Designation*

*

Father's Name *

*

Date of Birth *

*

Age *

* *

Postal Address *

*

State*

*

Dist*

*

Rural/Urban*

*

Block Name*

*

Pin Code*

**

Adhar Number *

*

PAN Card Number *

* *

Mobile Number *

* *

Email-ID *

*

Particulars of Agent/Manager of Contractor

Full Name*

*

Designation*

*

Father's Name*

*

Postal Adress*

*

State*

*

Dist*

*

Rural/Urban*

*

Block Name*

*

Pin Code*

* *

Adhar Number *

*

PAN Card Number*

* *

E-Mail ID*

*

Mobile Number*

* *

Information on Establishment of Principal Employer

Category of Establishment

*

Is Establishment

Government

Private

Whether Contractor was convicted of any offence withing preceding five years?

Select One*

YES

NO

*

Whether any order Passedagainst the Contractor Revoking/Suspending License/Forfeiting Security Deposit ?

Select One*

YES

NO

*

Select One*

YES

NO

*

Whether Certificate issued By Principal Employer In FORM -V enclosed

Upload Form V

*

Download FOrm FORM -V Formate

क्या आप अपने पुराने अनुज्ञप्ति की प्रतिभूती राशी का समायोजन करना चाहते है

YES NO

Payment of License Fee

E-Chalan (Chalan Head =>0230 श्रम और रोजगार 106 संविदा श्रमिक (विनिमय उन्मूलन) एक्ट के अंतर्गत प्राप्तियां)

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E-Chalan(Treasury Ref) Number

*

License Fee

* * + =
Total License Fee

Security Deposit

E-Chalan(Chalan Head =>K Deposite Advance (6) Deposite Not Bearing Intrest
8443 Civil Deposite 116 Deposite under Various Contacts
Labour /Regulation and Abolition/Act 1970 (Security Deposite)

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Chalan Number

Security Deposite

* *

User Detail

User Name

*

Password

*

Mobile Number

* *

Telephone Number

I hereby declare that the particulars given and document uploaded here in above are true to the best of my knowledge and belief