APPLICATION
FORM FOR GRANT OR RENEWAL OF LICENCE
FORM – ‘A’
(See rule 6(a)
To
The
Licensing Authority,
....................................
....................................
I/We
(Name in block letters).............................................. age ........
sex .... By occupation .......................... son/ daughter/ wife of
..................................................... Residing at
........................................... apply for the grant / renewal of
licence under the provisions of the PFA Act,1954 (Central Act 37 of 1954) and
rules made thereunder, for the manufacture for sale/storage for
sale/sell/distribution of /sale of
**..........................................................................................................................................
by wholesale / retail, within the limits of***
.................................................in the premises situated
the temporary stall at .............................................
as..................................... measuring ..................... sq.mtr
situated at ...................................... for a period of
.................. upto ............................... My /our annual
turnover is of Rs...................................................
I/We
shall abide by the Prevention of Food Adulteration Act,1954 and the rules made
thereunder and carry on the aforesaid trade subject to restrictions and
conditions imposed by the licence granted to me / us.
The
amount of Rs......................in cash/treasury/receipt for the fees for
licence as per schedule is enclosed herewith.
I/We
are also enclosing herewith Medical Officer Certificate inForm-B of my /our own
and also that of my/our employees.
In
my/our absence Shri/Smti.............................................age..................sex.............
Address............................................................shall
conduct the above said business
The
statement made above are true to the best of my/our knowledge and belief and if
nay is found to be false or not true the licence shall be liable to be
cancelled.
NOTE:-
In case of partnership or the limited company or Co-operative Society, an
attested copy of the partnership deed or the article of association or the
Registration Certificate issued, should be attached herewith.
*Specify
the district of the State
**Specify the article of food.
***Specify
the local area.
Signature of Applicant