| |
|
Replies to be written in this column. |
| 1. |
Name in which licence is required |
________________________________________________ |
| 2. |
Status-individual/registered/unregistered Company |
________________________________________________ |
| 3. |
Age (for individual only) |
________________________________________________ |
| 4. |
Postal address |
________________________________________________ |
| |
Pin Code |
________________________________________________ |
| |
Telephone No. |
________________________________________________ |
| |
Telegraphic address |
________________________________________________ |
| |
Telex |
________________________________________________ |
| 5. |
Situation of the premises |
________________________________________________ |
| |
State |
________________________________________________ |
| |
District |
________________________________________________ |
| |
Town or Village |
________________________________________________ |
| |
House No./Municipal No. |
________________________________________________ |
| |
Police Station |
________________________________________________ |
| |
Railway Station |
________________________________________________ |
| 6. |
Quantity of Carbide proposed to be imported and stored |
________________________________________________ |
| 7. |
*Quantity of Carbide already stored in the premises |
________________________________________________ |
| 8. |
*Form in which licence is required |
________________________________________________ |
| 9. |
*Number of licence held for the premises and the full name and address of the holder of the licence |
________________________________________________ |
| 10. |
Enclosures : |
________________________________________________ |
| |
*(i)Plan No.________ Approved by _______Vide letter No._____________ dated_____________(in triplicate/quadruplicate)
|
|
| |
(ii) Licence No._______________ dated_______________ |
|
| |
(iii) Bank draft/Cheque No./Postal order No. |
|
| |
Dated__________________ |
|
| |
for Rs._________________ |
|
| |
Drawn at_______________ |
|
| |
|
| |
I certify that the information given above is correct. |
| |
|
| |
|
Signature of the Applicant__________________________ |
| |
Place:_________________ |
Designation/Status _______________________________ |
| |
Date__________________ |
Full Postal Address_______________________________ |