Department of Labour Government of Tamil Nadu THE TAMIL NADU CONTRACT LABOUR RULES, 1975 FORM IV [See Rule 21(1)] Application for licence 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 of contractor at the worksite. : d. Maximum No. 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, Establishments and nature of work. : 8. Whether a certificate by the Principal Employer in Form V is enclosed. : 9. Amount of licence fee paid. - No. of treasury Challan and date.] : 10. 1[Particulars of security deposit, if any requested to be adjusted, including Treasury Receipt number and date. : 11. The amount of security or balance, if any, after adjustment of amount to be refunded under rule 31, deposited with Treasury Receipt number and date.] : Declaration. I hereby declare that the details given above are correct to the best of my knowledge and belief. Place: Signature of the applicant Date: (Contractor) Note: The application should be accompanied by a Treasury Receipt for the appropriate amount and a certificate in Form V from the Principal Employer. (To be filled in the office of the Licensing Officer) Date of receipt of the application with challan for fees/Security Deposit. Signature of the Licensing Officer. FORM V [See Rule 21(2)] Form of Certificate by Principal Employer Certified that I have engaged the applicant (name of the Contractor)as a contractor in my establishment. I undertake to be bound by all the provisions of the Contract Labour (Regulation and Abolition) Act, 1970 and the Tamil Nadu Contract Labour (Regulation and Abolition) Rules, 1975, insofar as the provisions are applicable to me in respect of the employment of contract labour by the applicant in my establishment. Place: Signature of the Principal Employer. Date: Name and address of establishment.
