Form XXII — Proforma of Licence

Rule: Rules 89(1), 90(2) · Signed by: State Authority · Under: OSH & Working Conditions (Central) Rules 2026

What the form records

• Licence No.
• Reg. No.
• Date of Reg.
• Licence is hereby granted to
• for the premises known as
• situated at
• nature of work
• The ______ 20.. (date of issue)
• Issuing Authority
• Sl.No.
• Period of issue
• Valid For - Maximum number of Contract labour on any one day
• Fee
• Date of Payment
• Excess fee for late payment
• Date of payment (late fee)
• Signature of the Issuing Authority
• Amendments - Year when Amended
• Amendments - Maximum number of Contract labour on any one day
• Amendments - Date of payment of amendment fee
• Amendments - Date of Payment
• Amendments - Signature of the Issuing Authority
• E-sign/digital sign of the designated authority

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

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