FORM ‘A’

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[See Rule 3 (1)  and 8  ]

(    Application for Licence/ renewal  )

 

1. Name of applicant for license  :-

   ( in full)

2. Profession:-

    

3. Full Address

4. Father’s  name in full

( in case of firm, give names and address of partners

and person holding powers of attorney to act on behalf

of the firm).

 

5. Specific place or places of business

6. Financial status with details of persons i.e. property, annual

Payment of income  tax and any other relevant evidence regarding

financial status

           

     7.    Specific purpose for which license is applied for

           (Processing/storing/selling/trading)

 

     8.   Name of the mineral/ore for which license is required. 

 

     9        Evidence of payment of application fee

 

     10.   Name & address of persons/firms from whom the mineral/ores will

            be purchased/procured

 

 

      11.   Period for which license is required

 

      12.   In case of renewal the number and date of original  license

 

      13.   Detail of income tax/Sales tax clearance Certificate.

 

      14.   Any special ground for grant of license in favour of the applicant        

 

List of enclosures

 

 

 

 

DECLARATION

 

                 I/we hereby declare that/we have and understood all the provisions of the Orissa Mineral(Prevention of theft, smuggling and other unlawful Activities) Act,1989 and  Rules made thereunder and the conditions of the licence and, I/we to abide by the same.

 

 

 

 

            Date of application                                                                   Signature of the Applicant

                Place      

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