Labour Commissioner 
(TO BE SUBMITTED IN TRIPLICATE)
| 1. | FULL NAME OF THE FACTORY, WITH FACTORY LICENCE NO. IF ALREADY REGISTERED | ............................................. | ||
| 2. | (A) | FULL POSTAL ADDRESS AND SITUATION OF THE FACTORY. | ............................................. | |
| (B) | FULL ADDRESS TO WHICH COMMUNICATION RELATING TO THE FACTORY SHOULD BE SENT. | ............................................. | ||
| 3. | NATURE OF MANUFACTURING PROCESS/PROCESSES | |||
| (A) | CARRIED ON IN THE FACTORY DURING THE LAST TWELVE MONTHS (IN THE CASE OF FACTORIES ALREADY IN EXISTENCE). | .............................................
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| (B) | TO BE CARRIED ON IN THE FACTORIES DURING THE NEXT TWELVE MONTHS (IN THE CASE OF ALL THE FACTORIES) | .............................................
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| 4. | NAMES AND VALUES OF PRINCIPAL PRODUCTS MANUFACTURED DURING THE LAST 12 MONTHS | ............................................. | ||
| 5. | (I) | MAXIMUM NUMBER OF WORKER PROPOSED TO BE EMPLOYED ON ANY ONE DAY DURING THE YEAR | ............................................. | |
| (II) | MAXIMUM NUMBER OF WORKERS EMPLOYED ON ANY DAY DURING THE LAST 12 MONTHS | ............................................. | ||
| (III) | NUMBER OF WORKERS TO BE ORDINARILY EMPLOYED IN THE FACTORY. | ............................................. | ||
| 6. | (I) | NATURE AND TOTAL AMOUNT OF POWER (H.P. INSTALLED OR PROPOSED TO BE INSTALLED) | ............................................. | |
| (II) | MAXIMUM AMOUNT OF POWER (H.P.) PROPOSED TO BE USED. | ............................................. | ||
| 7. | FULL NAME AND RESIDENTIAL ADDRESS OF THE PERSON WHO SHALL BE THE MANAGER OF THE FACTORY FOR THE PURPOSES OF THE ACT. | .............................................
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| 8. | FULL NAME AND RESIDENTIAL ADDRESS OF THE OCCUPIER | |||
| (I) | THE PROPRIETOR OF THE FACTORY IN CASE OF PRIVATE FIRM/ PROPRIETORY CONCERN. | ............................................. | ||
| (II) | DIRECTORS IN CASE OF A PUBLIC LIMITED LIABILITY COMPANY / FIRM | ............................................. | ||
| (III) | WHERE A MANAGING AGENT HAS BEEN APPOINTED THE NAME OF MANAGING AGENT AND DIRECTORS THEREOF. | ............................................. | ||
| (IV) | SHAREHOLDERS IN CASE OF PRIVATE COMPANY WHERE NO MANAGING AGENT HAS BEEN APPOINTED. | ............................................. | ||
| (V) | THE CHIEF ADMINISTRATIVE HEAD IN CASE OF A GOVERNMENT OR LOCAL FUND FACTORY. | ............................................. | ||
| 9. | FULL NAME AND ADDRESS OF THE OWNER OF THE PREMISES OR BUILDING (INCLUDING THE PRECINCTS THEROF) REFERRED TO IN SECTION 93 | ............................................. | ||
| 10. | IN CASE OF FACTORY CONSTRUCTED OR EXTENDED AFTER THE DATE OF THE COMMENCEMENT OF THE DELHI FACTORIES RULES, 1950. | ............................................. | ||
| (A) | REFERENCE NUMBER AND DATE OF APPROVAL OF THE PLANS OR CONSTRUCTION OR EXTENSION OF FACTORY BY THE CHIEF COMMISSIONER/ CHIEF INSPECTOR. | ............................................. | ||
| (B) | REFERENCE NUMBER AND DATE OF APPROVAL OF THE ARRANGEMENTS, IF ANY MADE FOR THE DISPOSAL OF TRADE WASTE AND EFFLUENTS | ............................................. | ||
| 11. | AMOUNT OF FEE RS. …………………………................……………… (RUPEES..............……..) PAID IN ………………………………….....…………….. TREASURY…………........………………. ON ………....…………….. VIDE CHALLAN NO………………………...............………. (ENCLOSED). | |||
| SIGNATURE OF OCCUPIER.............................. | |
| DATE ………………... | |
| SIGNATURE OF MANAGER.............................. | |
| DATE ………………... | |
| NOTE:- | |
| 1. | THIS FORM SHOULD BE COMPLETED IN INK IN BLOCK LETTERS OR TYPED. |
| 2. | IF POWER IS NOT USED AT THE TIME OF FILLING UP THIS FORM; BUT IS INTRODUCED LATER; THE FACT SHOULD BE COMMUNICATED TO THE CHIEF INSPECTOR IMMEDIATELY. |
| 3. | IF ANY OF THE PERSON NAMED AGAINST ITEM 8 IS MINOR, THE FACT SHOULD BE CLEARLY STATED. |
| 4. | IN THE CASE OF A FACTORY, WHERE UNDER THE PROVISION OF SUB-SECTIONS 1 AND 2 OF SECTION 100, A PERSON HAS BEEN NOMINATED AS THE OCCUPIER, INFORMATION REQUIRED IN ITEM 8 SHOULD BE SUPPLIED ONLY IN RESPECT OF THAT PERSON |
| 5. | IN THE CASE OF FACTORY WHERE A MANAGING AGENT OR AGENTS HAVE BEEN APPOINTED AS OCCUPIERS UNDER THE INDIAN COMPANIES ACT, 1913(VII OF 1913), INFORMATION REQUIRED IN ITEM 8 SHOULD BE SUPPLIED ONLY IN RESPECT OF THAT PERSON OR PERSONS. |