Place*

Full name of the person who
shall be the employer for the purposes of the Act*

Full Name of Industrial Premises *

Residential address of the person who
shall be the employer for the purposes of the Act*

Full postal address of the industrial premises*

If Partner

Full address to which communications relating to the industrial premises should be sent*

Name of Partner

Full address of the applicant *

Residential Address*

No.of Male Employees *

Financial Resource of the Employer

No.of Female Employees

Whether the employer is a trade mark holder registered
under the Trade and Merchandise Marks Act, 1958

Source of obtaining tobacco*

Value of beedis or cigars or both manufactured at the
industrial premises during the preceding financial year

Email*

Previous Experience of the Applicant in the industry

Mobile Number *

Whether the Plans of the Premises are Enclosed

Whether Beedi/Cigars or both Manufactured by the Applicant