Form XXI — Application for Grant / Renewal / Amendment of Licence

Rule: Rules 87, 88(1), 96(1) · Signed by: Occupier · Under: OSH & Working Conditions (Central) Rules 2026

What the form records

• Labour Identification Number
• Date
• Acknowledgement Number
• Date of Application
• Name of Establishment
• Head Office address along with email Id
• Corporate office address along with email Id
• Telephone Number
• Activity as per National Industrial Classification (Select all applicable activities given)
• Details of selected NIC Code
• Nature of work carried on in main establishment
• Identifier of the Establishment (Select) : e-sign/digital sign
• Full Name of Employer
• Relationship with establishment
• Full Address of Employer
• Email Id of employer
• Mobile No. of employer
• Locations of worksites
• Name of works
• Activity as per national industrial classification
• Date of commencement
• Date of completion
• Name of Establishments in which contract labour is/proposed to be employed
• Name Address, email id of the Site Incharge
• Maximum number of workmen proposed to be employed on the establishment on any date
• Amount of Licence Fee: INR
• Licence Fee Transaction Id
• Amount of Security Deposit: INR
• Security Deposit Transaction Id
• Common Licence - Type of Establishments
• Common Licence - Name & Address of establishment
• Common Licence - Nature of work carried out / Activity as per National Ind'l classification
• Common Licence - Date of commencement
• Common Licence - Permanent establishment or probable date of completion
• Common Licence - Maximum number of contract labour employed/proposed to be employed
• Single Licence - Name of States in which the establishments are situated
• Single Licence - Name of each work
• Single Licence - Maximum number of labour will be/is employed
• Single Licence - Date of commencement
• Single Licence - Permanent establishment or probable date of completion
• Single Licence - Registration number, if obtained, then details thereof
• Signature of Contractor (e-Sign/DSC)
• Renewal - Licence No.
• Renewal - Date
• Renewal - LIN & PAN
• Renewal - Name and address of the establishment
• Renewal - Date of expiry of previous licence
• Renewal - Whether the licence of the employer/contractor was suspended or revoked
• Renewal - Amount of fees paid (Enclose e-payment receipt)
• Renewal - Date of payment
• Renewal - E-sign/digital sign of the employer/contractor
• Amendment - Licence No
• Amendment - Date
• Amendment - LIN & PAN
• Amendment - Name and address of the establishment
• Amendment - Maximum number of contract labour presently employed
• Amendment - Details of fees paid through e-payment date on which made
• Amendment - Other details requiring amendment in the licence issued
• Amendment - E-sign/digital sign of the employer/contractor
• Date of application
• Place

This page opens the blank statutory form in MedFactory, ready to fill, save and print. See the Form XXI reference page for the rule and signatory detail.

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