FORM IV

(See rule 21 (1))

Application of License

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 labour 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 labour :

(a) Nature of work in which contract labour 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 or contractor at the work

site.

(d) Maximum number of contract labour 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

licence 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, establishment and

nature of work.

8. Whether a certificate by the principal employer in Form V is enclosed.

¹[9. Amount of licence-fee-Name of the Union Bank, Demand Draft No. and

date.

10. Amount of security deposit-Name and Union Bank, Demand Draft No. and

date.]

"The amount of security or balance, if any, after adjustment of amount to be

refunded under rule 30, if any, deposited with treasury receipt number and date."

Declaration.-1 hereby declare that the details given above are correct to the best

of my knowledge and belief.”

           Place :

         Date :

                                  Signature of the applicant

                          (Contractor).

¹[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.]

(f o be filled in the office of the Licensing Officer)

Date of receipt of the application with challan for fee of security deposit.

Signature of the Licensing Officer .

1.Subs. by G.S.R. 657, dated Ilth August, 1987 (w.e.f. 22nd August, 1987)