PUNJAB GOVT. GAZ. MARCH 14, 2003-11-28 (PHGN 23, 1924 SAKA) FORM 'A' [SEE CLAUSE 9(1) AND (4)] THE PUBLIC DISTRIBUTION SYSTEM (LICENSING AND CONTROL ORDER, 2003) APPLICATION FOR GRANT / RENEWAL OF LICENSE 1. Applicant's Name ____________________________________ 2. Father's Name _______________________________________ 3. Mother's Name _______________________________________ 4. Applicant's Profession __________________________________ 5. Applicant's Address ____________________________________ 6. Address of Applicant's place of business with particulars as to member of house, mohalla, town or village, police station and district_______________ _____________________________________________________________ 7. Complete address of the place where public Distribution system items are proposed to be stored __________________________________________ I declare that I was never convicted by a court of Law in respect of any order made under Section 3 of the essential commodities Act, 1955. I further declare that no license in respect of Public Distribution Systems items issued to me under the provisions of the Essential Commodities Act, 1955 or any other order made there under was ever suspended of cancelled. I have carefully read the conditions of license given in form 'B' appended in the Punjab Public Distribution System (Licensing and control order, 2003) and I agree to abide by them------- *(a) I have not previously applied for such license in any other district for Public Distribution System items *(b) I applied for such license in other district namely ______________________ ___________________ for Public Distribution System items on _________ ______________________ and was / was not granted a license. *(c) If yes, No. of License _____________________________ *(d) I hereby apply for renewal of License No. ____________________ dated ________________ issued to me on ____________________ Strike off clause whichever is not applicable Signature of the Applicant Place __________________ Dated __________________
