1
FIFTEENTH SCHEDULE
(section 88)
APPLICATION FOR THE REGISTRATION OF A FACTORY
I…………………………………… on behalf of………………….……………. hereby apply for registration/renewal
of certificate of registration to operate a factory as from………………………… and particularised as hereunder:
1. (a) Name of employer…………………………………………………..
(b) Address of employer…………………… Tel. No………………….
(c) Registered office or principal place of business of company, societe or corporate body………………………….……………………….
2. Address of the factory…………………………………….…………………
3. Nature of the process or manufacture carried or intended to be carried on at the factory…………….……………………….……………………….
4. Number of employees:
Male…………………………. Female………………………….…
Young persons: (Male)… …………. (Female)… …………….
Total………………………
5. State number and particulars of welfare facilities:–
(a) Sanitary conveniences for:
male employees………………….…………….
female employees……………………..………
(b) Washing facilities ……………….……………………………..……………
(c) Mess or facilities for the taking of meals ………………….….….
(d) Accommodation for clothing or changing room:……………….
6. (a) Total power used or generated by machinery installed in the factory ……………………………………………………………………..
(b) Responsible person in general charge of all machinery:
(i) Name………………………….……………………….
(ii) Address………………………….……………………..
(iii) Qualifications………………………….……………….
7. This paragraph applies to every employer of 100 or more employees or as directed by the Permanent Secretary–
(a) (i) Name of person responsible for safety, health and welfare at the place of work ………………………………………………..
(ii) Position held ………………………………………………..
(b) (i) Name of registered safety and health officer
…………………………………………………………………
(ii) Private address ……………………………………………..
8. List any machinery or equipment which are used or intended to be used in the factory:–
Number in use
(a) Steam Boiler ……………………….
(b) Steam Receiver ……………………….
(c) Air receiver ……………………….
(d) Hoist and Lift ……………………….
(e) Crane and other lifting machine ……………………….
(f) Woodworking machine ……………………….
(g) Refrigeration plant ……………………….
(h) Vehicle Lift ……………………….
(i) Escalator ……………………….
(j) Other machines ……………………….
9. State whether substances hazardous to health, corrosive or flammable substances are used, manufactured or likely to be formed in the course of any process………….……………………….……………………….
If yes, give the names and quantities of these substances
……….……………………….……………………….……………………… …………………….……………….……………………….………………..
10. State whether the factory building is new ………………..
Signature of applicant: ……………….…………………
Name: ……………….…………………
Status: ……………….…………………
Date: ……………….…………………
FOR OFFICE USE ONLY
I
The application is–
*(a) approved with conditions for period……………. …..to………………
*(b) approved without conditions for period …………… to ………………
*(c) Not approved.
Date: ………….…………. ………….:…………………..………….
for Director, Occupational Safety and Health
*Delete whichever is not applicable.
II III
Rs cs
Registration Fee: ……. Factory Building Permit Fee: Rs……..
(already paid)
Surcharge (50%): ……. Receipt No.:……………….
TOTAL: ……. Certificate No.:…………….
Date of issue:………………
File No.: …….…….…….…….……..
Receipt No.: …….…….…….…….……..
Certificate No.: …….…….…….……
Date of issue: …….…….…….……
Date of expiry: …….…….…….……
…….…….…….…….…….…….…….… ….…….…….…….…
Signature of Issuing Officer for Director, Occupational Safety and Health
Date: … …….…….…….…….…….……. Date: :… .…….…….…….…….…….