| To Whom application to be addressed: : | * |
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| To Chief Inspector |
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| 1. Employer’s Name (Note ii): | * |
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 Street Name and Number (Note i): | * |
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| Suburb / Village / Town: | * |
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| Parish (Note i): | * |
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| District: | * |
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| Other Details: | |
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| Activity (describe main economic activity e.g. manufacturing of metal components, etc) | * |
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| Other details concerning the employees, the work place and the equipment. |
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| 3.1.(a) Number of persons employed or intended to be employed in the near future: |
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| Total Number: | * |
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| Men: | |
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| Women: | |
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| b) Please write number of persons employed, or indented to be employed in shifts or maximum number of persons employed or intended to be employed in any one time: | |
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| 3.2 Working hours: | * |
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| 3.3. Minimum and maximum wages, excluding apprentices: |
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| For Men: | |
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| For Women: | |
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| 3.4. Description of main power driven machinery installed or intended to be installed: | |
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| 3.5. Description of steam boiler (if there is any): |
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| (a) Type, description and distinctive number: | |
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| (b) Country and year of manufacture: | |
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| (c) Date of the last thorough examination and name of person by whom the examination was made (DD/MM/YYYY) | |
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| (d) Maximum permissible working pressure in Bars | |
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| 3.6. (a) Description of premises (number and use of rooms e.g. production area, maintenance workshop, office, store, etc). | * |
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| (b) Total size of premises (m²) | * |
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| 4. Applicant’s particulars |
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4.1 Postal Address
(fill at least one of the two sections A or B) |
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| Α. | | |
| Street Name and Number (Note i): | * |
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| Suburb / Village / Town: | * |
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| Parish (Note i): | * |
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| District: | * |
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| Postal code of street / Village: | * |
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| P. O. Box: | * |
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| Postal Code of P. O. Box: | * |
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Area of P. O Box
(Town / Suburb / Village): | * |
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| 4.2. Telephone: | * |
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| 4.3. Fax: | |
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| 4.4. E-mail address: | |
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| 5. Declaration by the applicant |
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| 5.1 I hereby undertake to observe the provision of any legislation which is in force and is concerning the Safety and Health at Work as well as the Factories Law, in so far as they apply to these premises. |
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| 5.2 Name and surname of (employer) in case of a private or name of the responsible person who applies on behalf of the applicant in case of a company or an organization: | * |
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| 5.3 Post (e.g. Director): | * |
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| 6. Documents which are being submitted electronically: | |
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