F O R M IL 11-A (Rule 30 (1)) APPLICATION FOR GRANT OF CLUB LICENCE IN FORM IL-20 1. Name of the applicant : 2. Name and style of proposed licence : 3. Full address of the premises to be licenced : 4. Registration number and Date of Registration : 5. Whether copy of Bye-laws and Article of Association enclosed : Yes/No 6. No. Of members and number who have paid their membership fees for the last three years : 7. a) Total area of club premises(in Sq.mts) : b) Built-up area (in Sq. Mts) : 8. Whether the club is located in its own building or in a building provided by the Govt.? : Yes/No 9. Size of Bar room (in sq. Mts) : 10 Whether the club has the following facilities i) Billiards : Yes/No ii) Lawn tennis/Table tennis : Yes/No iii) Shuttle Badminton/Ball badminton : Yes/No iv) Gymnasium / Health Club : Yes/No v) Swimming pool : Yes/No 11. Whether there is kitchen for cooking and serving complete meals: : Yes/No 12. Whether there is separate dinning room/ dinning area for serving meals: : Yes/No 13. Whether separate toilet facilities are provided for male and female? : Yes/No 14. Whether the club has been convicted of offences under the provisions of Excise Act, Customs Act of Narcotics Drugs Act, A.P. Intoxicating Liquor (Prohibition of Advertisement ) Act, 1978 or any Non- Bailable offence : I hereby, declare that the particulars given above are true to the best of my knowledge and belief. If at a later stage any of the facts are found to be false the licence may be cancelled and I may be prosecuted as per the Andhra Pradesh Excise Act, 1968 or the Rules thereunder. I hereby, under take to abide by the rules, licences and conditions prescribed under the Andhra Pradesh Excise Act, 1968. Signature of the Applicant PART - B Particulars of brands of varieties of Indian Liquor the applicant desires to sell Kinds of Indian Liquors Brands a) Brandy b) Whisky c) Rum d) Gin e) Wines f) Beer g) Vodka h) Others Signature of the Applicant
