FORM A (See Clause - 4 (I)) THE ANDAMAN AND NICOBAR ISLANDS FOODGRAINS DEALERS LICENSING ORDER, 1963. 1. Applicant's name 2. Applicant's Profession 3. Applicant's Residence 4. Situation of applicant's place of house, mohallaa town, village and Police Station. 5. How long has the applicant been trading in foodgrains. 6. Did the applicant hold a foodgrains licence on any previous occasion (if so give particular including its suspension of cancellation if any) 7. Quantities of each foodgrains handled annually during the last three years 8. Quantity of foodgrains likely to be handled during the current year. 9. Income Tax paid in the two years proceeding the year of application (to be indicated separately) 1. 2. 10. (A) Quantity of foodgrains in the procession of the applicant on the date of application Separate figures are to be given for each foodgrains. (B) Complete address of place where foodgrains are proposed to be stores. I declare that the quantities of foodgrains specified above are in my possession this day are held at the place noted above. I have carefully read the conditions of licence given in Form "B" appended to the A&N Islands Foodgrains Dealers Licension Order 1965 and I agree to abide by them. (a) I have not previously applied for such licnence for foodgrains. (b) I applied for such licence for and was not granted a licence . (c) I hereby apply for renewal of licence No...........dated......... Issued to me on........... (d) I hereby apply for re-issue or he licence No........dated........issued to me but subsequently cancelled. ------------------------------------------------------------------------------------------------------- Strike off the clauses not applicable. Signature of the applicant Place: Date:
