भारत सरकार
GOVT. OF INDIA
श्रम एवं रोजगार मंत्रालय
MINISTRY OF LABOUR AND EMPLOYMENT
खान सुरक्षा महानिदेशालय
DIRECTORATE GENERAL OF MINES SAFETY

Applicant Registration

Name of The Company *

Type of Company *

Date of establishment of business

Applicant Details

Name of The Applicant *

Designation of Applicant *

Address *

Country *

State *

City *

Pincode *

Email *

Mobile No. *

Contact No.

FAX

Photo of Applicant *

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About Company Same As Applicant Data

Company Address *

Email *

Country *

Contact No.

State *

TIN/PAN No.

City *

FAX

Pincode *

Company Logo

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Details of the Indian Agent

Name Of Indian Agent *

Email *

Designation of Indian Agent *

Mobile No. *

Address *

Contact No.

Country *

TIN/PAN No.

State *

FAX

City *

Pincode *

Whether, The CEO/Owner/Proprietor of the manufacturing Foreign firm shall submit along with the application, His written authorization in original to be Indian Agent for the purpose of various follow-up etc., or not.

Authorization Document *

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Details Of Factory Same As Company Data

Name of Factory

Email *

Address *

Contact No.

Country *

FAX

State *

City *

Pincode *

Enclose the relevant certificate if any:

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Certificate of Incorporation issued by Registrar of firms or Societies (enclose attested copy of certificate) : *

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Registration number alloted by the State & Director of Industries (enclose attested copy of certificate) : *

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Signature*

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Aadhar Number

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Letter Head*

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Power of Attorney Certificate

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