Labour Department

Form V

Application for License for Employment of Migrant Workman

Fields marked with * are mandatory.

Contractors Detail

1. Contractor Type *:

2. Name of Contractor *:

3. Address of Contractor *:

a. District *

b. Tehsil *

c. City/Village *

d. Survey No. *

e. Postal Code *

4. Mobile No. * :

5. Email id:

6. Name of employer's Father/ Husband :

(In case of Individuals)

7. Date of Birth :

(In case of Individuals)

Particulars of Establishment where migrant Workmen to be employed

1. Name of the Establishment *:

2. Address of the Establishment *:

3. Type of business,trade, industry, manufacture or occupation, which is carried on in the establishment *:

4. Number and date of certificate of registration of the establishment under the Act *:

5. Full name of the Principal Employer *

6. Address of Principal Employer *:

Particulars of Migrant Workmen

1. Nature of work in which migrant workmen are employed or to be employed in the establishment *:

2. Estimated date of commencement of of proposed contract work*:

3. Estimated date of termination of proposed contract work *:

4. Name of the Manager/ Agent of the contractor at the work site*:

5. Address of Manager / Agent *:

6. Name of the Director/ Partner :

(In case of companies and Firms)

7. Address of Directors/ Partner :

8. Name(s) of the person(s) in-charge of and responsible to the company/ firm for the conduct of business :

(as the case may be)

9. Address of incharge :

Other Details

1. Whether the contractor was convicted of any offence within proceeding five years*:

Yes

2. Whether there was any order against the contractor revoking or suspending license or forfeiting security deposits in case of an earlier contract.*:

Yes

3. Whether the contractor has worked in any other establishment within past five years*:

Yes

DECLARATION

This is to certify that the information furnished is true and correct to the best of my knowledge and belief. I also affirm that in case, I have provided wrong information, I am liable for action by Competent Authority.

NOTE:- All Documents have to be in pdf format and size less than 500KB each and clearly legible for approval by Department. All documents are to be uploaded .

S.No.

Documents

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