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1. Name of the Establishment '.

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2. Previous details of Establishment :

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(i) Registration No. :

(ii) Application lD No. :

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Registration No.
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4. Date of Expiry :

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5. Postal address and situation ofthe :

Establishment

6. Date of commencement of Business :

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Nature of Business
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Whether Establishment falls under : Public / Private
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Note-(a)EstablishmentinPublicsectormeansanestablishmentownedormanagedby(i}
defined in
the Government or Department ofthe Government (ii) a Government Company as
(iii) a corporation (including
clause (45) of Section 2 of the companies Act, 2013 (1s of 2013)
co-operativesociety)establishedbyorunderanycentralActorState]Actwhichisowned,
controlled and managed by the Government (iv) a Local Authority
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(b) Establishment in Private Sector means an establishment which is not an establishment
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9 Name of the Employer

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Residential Address of the Employer
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Mobile No. And E-mail tD
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Adhar Card No. (upload copy) 330550724654
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10 Name, Address, Mobile No. And E-mail lD
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11 (a) Category of Establishment commercial
i.e. Shop/Commercial Establishment/
Residential Hotel/ Restaurant / Theate /
Other places of public amusement or
entertainment and other Establishment
(b) Type of Organisation
i-e. Proprietor, Partnership, LLp, Company
/ Trust / Co-operative Society / Board
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12 Name ofthe member of employe/s Name of the person Relation
family employed in the establishment - ?

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13. Self-Declaration
t/We hereby solemnly affirm and state that the business which l/We have started is not
banned or prohibited by any Act, Rules, Law or Order of any court of Law or any competent
authority and the premises where l/We are conducting the said business is free from violation of any
Act, Rulet Order of any Court of Law or any Competent Authority.
l/We hereby declare that the information provided above is true and correct to the best of
my personal knowledge, information and belief. I am fully aware about the consequences of giving
false information. lf the information is found to be false, I shall be liable for prosecution and
punishment under the lndian Penal Code (45 of 1850) and / or any other law applicable thereto.
l/We have obtained necessary licenses, permissions, permit for the conduct of this business
and the place of business from the appropriate Authority.
l/We shall be responsible and liable for legal action if the business is conducted without
proper licence, permission, permit from the appropriate Authority.
l/We submit and declare that l/We will not undertake any illegal activity or any business
prohibited in law in force in lndia.
l/We declare that the place of business is not located in any area wherein commencing/
running of such business is prohibited by any law or order of any Competent Authority.
l/We declare that the copies attested by me are true copies of original documents. I am well
aware of the fact that if the copies are found false/forged, I shall be liable for prosecution and
punishment under the lndian Penal Code (45 of 1850) and / or any other law applicable thereto.
l/We undertake to abide by the provisions of the Maharashtra Shops and Establishment
(Regulation of Employment and Conditions of Service) Act, 2017 (Mah.LXl of 2017) and the Rules and
orders passed there under by any Authority.

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Date :

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Place: Name and Signature of Applicant