Self Certification Application Form

Establishment Details
Name of Establishment *   Plot No./House No./Name *  
Street/Locality *   Village/Town/City *  
District *   Mobile Number*  
FaxNo. Email*  
Registration/Licence No. *   Nature of Business*  
Owner Occupier Details
Name of owner/occupier *   Plot No./House No./Name *  
Street/Locality *   Village/Town/City *  
District *   Mobile Number*  
FaxNo. Email*  
Fee Details
Number of workers*   Number of Workers Employed*  
Registration Fee in Rs*   Amount of Security Deposit in Rs*  
Attachments (Scan and Upload the Documents in .pdf and below 250KB)
1) Registration Certificate under Karnataka Shops and Commercial Act 1961 and Karnataka Rules 1963/ Licence obtained under Factories Act 1948/ Registration Certificate of Principal Employer/ licence of Contractor under the Contract Labour( regulation and Abolition) act ,1970, Registration Certificate under the Plantation Act,1951, Registration Certificate under Motor Transport Workers Act, 1961, License under the Beedi & Cigar Workers (Conditions of Employment)Act, 1966; The Inter State Migrant Workmen (regulation of Employment and Condition of Service) Act, 1979, Registration Certificate under the Building and other Construction workers( Regulation of Employment and Condition of Service) Act, 1996 and any other laws which is applicable. *  
2) ESI EPF Registration Certificate/ Challan *  
3) Details of fees and Security Deposit paid Documents *  
4) Permanent /Postal Addresses and ID Proof of each and every Partners /Propreitors/ Directors/ Occupiers *  
5) Rent Agreement/ Ownership deed/Lease deed *  
6)Copy of Memorandum of Association and Articles of Association ,in case of private Limited/Public Companies *  
7) Partnership deed in case of partnership Firm *  
8) Registration /Licence obtained under any Central/State Agencies(GST) *  
9) Declaration under non employment of Child labour and adolescent Labour *  
10)Phone,Mobile number,E-mail ID's of proprietor/Partners/Directors/Occupiers/Contractor/Employer for Communication *  
11) Any other Related Documents
12) Self Declaration Form *  
Declaration: I/We have gone through the provisions of the karnataka State Self Certification-Cum-Integrated Periodic Returns Scheme- 2015 and have understood the same .I/We wish to be registered under the said scheme. The necessary Information and other documents as required under the scheme are herewith submitted for your consideration and acceptance. I /We undertaketo abide by all terms and conditions of the scheme. It is also certified that I/We are competent and duly authorized to make any statement or provide any information to any competent Authority of Labour Department on behalf of this establishment /enterprise.
Date Place Signature of the Applicant(Upload in .jpeg format and below 50KB) *