FORM IV [See Rule 21(1)] Application for Licence

1. Name and address of the Contractor including his :

22/3RT, Fathers name in case of individuals Hyderabad.500057.A.P. Mr.T.R.Mukherjee. 2. Date of birth and Age (in case of individuals) 3. Particular of Establishment where contact Labour is : CORPORATION LTD . To be employed. PROJECTS, AT-JHIMANI, (a)Name and address of principal employer: paradip 754141. (b) Type of business, trade, industry manufacture PROJECT) Or occupation, which is carried on in the Establishment. (c) Number and date of registration of the establishment: 04.11.2008. Under the act R-/13/2008 dated 04.11.2008. (DGM) (d) Name and address of the principal Employer. Ltd. Refinery Project. At. Jhimini, Dist: Jagatsingpur. Paradip, 754141. Orissa. 4. Particular of contact Labour: Construction of quarters, Refinerytownship (a) Nature of work in which contact Labour is Refinery projets Employed or is employed or is to be employed In the establishment (b) Duration of the proposed contract work (Give particular of proposed date of commencing 15/10/2010. And ending) (c) Name and address of the agent or manager of Contractor at work site. (d) Maximum number of contract Labour proposed only) (Phase- III) Paradip Paradip, Orissa. 15 Months. 16/07/2009 & IVRCL Infrastructures & Projects Ltd. MVijaynagar colony, Repesentive of ---------------NA-----------INDIAN OIL TOWNSHIP Dist: Jagatsinghpur,

: OIL REFINERY (UNDER

R-/13/2008 dated

UTPAL SEN : Indian oil corporation Paradip

: 200Nos(Two hundreds

To be employed in the establishment on any date. 1. Whether the Contractor was convicted of any offence NO Within the preceding five years, if so give details. 6 Whether there was an order against the Contractor Revoking or suspending licence or forfeiting security Deposites in respect of any earlier contract. If so, the date of such order. 7. Whether the Contractor has worked in any other Establishment within the last five years, If so gives .. Details of the Principal Employer Establishment And nature of work. 8. Whether a certificate by the Principal Employer .Yes In Form V is enclosed. 9. Amount of licence fees name of the Union Bank: demand draft No. and date. 10. Amount of security deposit Name of the Union Bank :

. No

.. NA

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Note: The application shall be accompanied by demand draft and the challan for the appropriate amount and a certificate in form V from the principal employer.dateof receipt of the application with demand draft and the challan for fees/security deposit. Declaration I hereby declare that the details given above are correct to the best of my knowledge and d behalf.

Place: Paradip Signature of the Applicant Date: (Contractor)

Note: The application should be accompanied be a Treasury Receipt for the appropriate amount and certificate in form V forms the principal Employer.

TOWNSHIP PROJECTS, AT -