| 1. | Full Name of the applicant (Block letter) |
: |
| 2. | Address of Correspondence | : |
| 3. | Name & Style of Trade | : |
| 4. | Relation of applicant with entity functionary under the name & Style |
: |
| 5. | Authority
of the applicant to seek permission from the entity support with due documents if any. |
: |
| 6. | In case
of liable action under any Section against whom proceeding should be taken. |
|
| (Indicate
name and address of the person with his written consent in the form accepted to the Chief Officer) |
: | |
| 7. | Decription
of the Trade Business premises (Location house No. Ward No. name of the street, area plot, area administration/ building prescribed given on drawing) |
: |
| 8. | Occupancy
certificate, NOC of owner on non-Judicial stamp paper duly executed before Executive Magistrate or Notary. |
: |
| 9. | House tax
payment receipt for current year a) Indicate type of business or b) Process of manufacturing in brief |
: |
| 10. | Indicate
the mode of consumption of smoke/and other pollution/disposal of drain water |
: |
| 11. | Whether
premises are fenced and guarded, if not what measures are taken to prevent danger if any likely to be carried out to the public or trespassers or nearby resident.> |
|
| 12. | Whether permission or licence has been granted by any other authority such as Chief Inspector of Factories Industries Department, Excise-Department and the nature of such Licence. |
: |
| 13. | No. of employees appointed. | |
| The above information given to me is true to the best of my knowledge and belief. | ||
| Vasco-da-Gama. | ||
| Dated: (Signature and name) | ||