FORM 1
(Prescribed under Rule 3)
Application for permission to construct, extend or take into use any building as a factory

 1.  Application for-
     (a) constructing of a new building

     (b) extending an existing building  taking into use any building as factory
          ( Tick one or more as applicable)

 2.  Applicant’s name and address
      ( In block letters)

 3.  Full name and postal address of the factory

     (a) Name

     (b) Address
          (Town or village/Disc./Pin. Code No.)

 4.  Please indicate also following details-

      (a)  Nearest Police Station – distance

      (b)  Nearest Railway Station – or Steamer Chart

      (c)  Nearest Public Hospital

 5.  (a) Whether already registered as factory                                  Yes/No

     (b) If yes,                                                                                       (1)  Registration No.

                   (2)  Licence No.

                   (3)  Date of renewal of licence

     (c) Does it fall in hazardous category under
          Section 2(cb)                                                                            Yes/No

     (d) If so, has site been approved U/s 41A?                                      Yes/No

     (e) Is so, date of approval                                                                             

6.  Particulars of plant to be installed :
     *To be enclosed only if the site has not been
     appraised in terms of Section 41A

 7.  Enclosures

     (a) Flow chart of the manufacturing process                                    Yes/No

     (b) Brief description of the process in its  various stages                  Yes/No

     (e) Plan, in triplicate, drawn to scale showing

          (i)  the site of the factory and immediate surrounding
              including adjacent buildings and other structures,
              roads, drains, etc.                                                                Yes/No

          (ii) the plan, elevation and necessary cross-sections
of the various building indicating all relevant details
relating to natural lighting, ventilation and means of
escape in case of fire. The plans shall also clearly
indicate the position of the plant and machinery, aisles

              passage-ways.                                                                      Yes/No

(a)  Such other particulars as required of the Chief Inspector
at the time of submission of the application.

                                                                                        Signature of applicant
                                                                                        Name of applicant
                                                                                         (In block letters)
                                                                                        Telephone numbers:

Date: