(To be submitted through the district magistrate/additional district magistrate/licensing authority from where the paper is published) APPLICATION FOR INCLUSION OF NEWSPAPER/ PERIODICAL IN THE GOVT APPROVED LIST FOR GOVERNMENT ADVERTISEMENTS 1. Name of Newspaper/Periodical : 2. Name and address of the Editor : 3. Name and address of the Publisher : 4. Name of the owner of the Printing : Press, where the Newspaper/periodical is printed 5. Name and address of the Printing Press : where the Newspaper/periodical is printed 6. Name of the owner or owners of the : Newspaper/periodical (Mentioning whether Ownership is proprietary, cooperative, private Limited or trust etc). 7. Periodicity of Publication : 8. Price per issue : 9. Circulation (this should be shown items : wise, namely (a) subscriber copies, (b) complementary copies, (c) voucher copies and (d) exchange copies and areas where it it circulated (e) language in which published. 10. Certificate of circulation figure to be : obtained from the District Information & Public Relations Officer concerned. 11. Whether the Newspapers/periodical deals : with literary, political, cultural or Socio-Economic or other aspects. 12. Whether the Newspaper/periodical has any : Political affiliation or subscribes to any political ideology or independent. I hereby affirm that the above particulars are true and correct to the best of my knowledge and belief. If any of the above information is found incorrect, my application shall be liable for cancellation. Date ___________ Signature of Applicant Place ___________
