Exice and Taxation Department Union Territory, Chandigarh Serial no. of the Application _______ Application Form to Apply for the Grant of Country Liquor (L-14 A)/ Indian Made Foreign Liquor Vend (L-2) for the Year 2008-09. 1. Name of the Applicant : 2. Father's/Husband Name : 3. Age (As on 01-01-2008) : 4. Sex (Male/Female) : 5. Complete Residential Address : 6. Whether applying in individual Capacity or as partners of partnership : Firm or Authorized person on behalf of a Company? 7. Whether applying on behalf of a company if yes, attach copy of resolution of Board : of Directors authorizing for the same In case of a registered company attach an Attested copy of list of Directors on the : Board of Directors of the applicant company 8. PAN No. with date of issue (An attested : copy to be attached) 9. Whether the person applying for the vend is having premises ownership/lease/rental in the locality/area of the vend applying for. If yes give shop no. & sector or villa ge etc. : With a proof of ownership/lease/rent 10. Whether solvency certificate(s) of all the partners attached, if yes, date and office : of its issue. 11. Date of registration of company with the Registrar of Companies locality/ location of the vend/vends for which application has been submitted. Whether applying for : country liquor vend (L-14A) or IMFL vend (L-2) category of the vend (A or B) 12. Amount of earnest money being paid : 13. No. & Date of Bank Draft alongwith the name and branch of issue of the draft : of earnest money I, ____________________________________S/o Sh__________________________________ the above mentioned applicant solemnly affirmed and declare as under: 1. That the above information is correct to the best of my knowledge and belief. 2. That I am neither a defaulter of Excise & Taxation Department nor ineligible to hold a license under the Excise Act and Rules. 3. That I shall obey and observe the provision of the Punjab Excise Act, 1914 as applicable to U.T. Chandigarh and the rules, order and conditions framed there under and the instructions/directions issued by the Excise and Taxation Department, U.T., Chandigarh from time to time. I also know/understand that violation of any of the above can lead to the cancellation of grant of license/rejection of may application for the grant of license. 4. That in the event of acceptance of my application for the grant of license, I shall deposit the license fee of the vend as per schedule prescribed in the Excise Policy for the year 2008-09. Date & Place: - Signature of the applicant Attested ........................................ Part- II (Slip for draw of lots) Application Sr. no. ___________ Location/locality of the vend _______________ Name of the Applicant _______________________ Signature of the Applicant ........................................ Part -III (Receipt) Application Sr. no. ___________ Received application form alongwith earnest money draft of Rs. _____________ for the grant of country liquor (L-14A)/ Indian Made Foreign Liquor (L-2) vend (location/Locality) _____________________________________Chandigarh for the year 2008-09 from Sh./Smt. ______________________________________________________________________ S/o, W/o, D/o __________________________________________________________________ r/o _____________________________________________________________________________ Date & Time: - Signature of Receiving official I, ______________________________________________S/o ____________________________ r/o _____________________________________________ do hereby solemnly affirm and declare as under: 1. That I have not been finally convicted of any non-bailable offence, by a criminal court. 2. That I have not convicted, or reasonably suspected of committing or conniving at the commission of any offence under the Punjab Excise Act, 1914 or the East Punjab Opium Smoking Act, 1948 or the East Punjab Molasses (Control) Act, 1948 or the Indian Power Alcohol Act, 1948 or the Narcotics Drug and Psychotropic Substations Act, 1985. 3. That I have not held a license in U.T., Chandigarh for the sale of any intoxicant that has been cancelled for failing to pay the license fee. 4. That I am not a defaulter of Income Tax and Sales Tax/ VAT under the Punjab General Sales Tax Act, 1948/ VAT Act, 2005 as applicable to U.T., Chandigarh. Place: Deponent Dated: Verification: Verified that the above statement of mine is true and correct to the best of my knowledge and belief and nothing has been concealed therein. Deponent Performa of Solvency Certificate PART-I 1. Name : ................. Affix your recent pass 2. Father's Name : ................ port size Photograph 3. Full Residential Address: duly attested by a House No. ....... Ward No. ........... Gazetted Officer Village/Town: ........ Tehsil ........... (with seal, full name Police Station: ........ District ......... & designation of the State ......................... Gazetted Officer) 4. Occupation: ...................... 5. (a) Name of Income Tax circle/ward where assessed : (b) PAN as assigned by Income Tax Department : AFFIDAVIT (On Non-Judicial Stamp of Proper Value as per the Stamp Act in force) 1. I ................... S/o ............. aged ...... Occupation ............. R/o House No. .......... Village/Town .................. Tehsil .............. and sincerely affirm and State as under. 2. I hereby declare that I am the sole owner/joint owner of the immovable property/properties mentioned below and I am in exclusive/joint possession and enjoyment of this/these property/properties with full legal rights and control and there are no encumbrances or any liabilities or charges on this/these properties. Description of immovable property/Properties Details of Properties including house/khasra/plot No. etc Location Extent of Ownership (full or share in the property/properties as per title deeds) Current Market value of property/properties as indicated in col.4 (a) Agricultural Land (b) Residential House (c) Other Immovable Property Vacant sites 3. In support of the contents of para 2, Certified copies of the documents (e.g. latest available Jamabandi, Title deeds etc.) mentioned below are also enclosed: (i) ..................................... (ii) ..................................... Place: ......... Signature of deponent Dated: .......... I ................. S/o ...................aged ............ Occupation .................. R/o House No. ...............Village/Town .................... Tehsil ................. Police Station............ District Correct and true to the best of my knowledge and are based on documents. Nothing is false as nothing has been concealed. So help me God. Place: ......... Signature of deponent Dated: .......... By Shri ................ S/o ................... Identified by Shri .............. S/o .................. the contents of this affidavit having been read over and explained to the deponent who having understood the same has put his signature/Thumb impression in my presence at ........ Judicial Magistrate/Executive Magistrate Full Name ............. Seal ................ ....................................... R/o ...........Tehsil............ Police Station ............... District ............. is solvent to the extent to Rs. (in figures) ............. (in word) Rs. .......... and the details of properties furnished by him are correct. The approximate market value of immovable properties based on the enclosed title deeds etc. and current market value relating thereto is Rs................ Tehsildar/Revenue Officer Place: ............... Full Name ............. Dated............... Seal .............. Countersigned by Additional Deputy Commissioner/Sub Divisional Magistrate Full Name ................. Seal ................. UNDERTAKING (To be furnished to the Excise & Taxation Department, U.T., Chandigarh) (On Non-Judicial Stamp of Proper Value as per the Stamp Act in force) I ............... S/o ............. Age ........... Caste ................ R/o House No ........... Village/Town ................. Tehsil ............. Police Station ................. District ................ do hereby state as under: 1. That I have indicated the property/properties owned & possessed by me in my affidavit submitted to the Department. 2. I undertake that I will not alienate or otherwise encumber the property/properties mentioned in my above referred affidavit & the solvency certificates furnished by me by way of Mortgage/Hypothecation/ Sale/Agreement for sale/Gift or Bequest in other manner till two months after full and final settlement of the contract and payment of all dues by me to the State Government. 3. I further undertake that for any act done by me in breach of the above undertaking furnished by me. I shall be liable for action for committing criminal breach of trust. Place............ Signature with full Name address ............. Dated........... Note: - It is to be attested by a Judicial or Executive Magistrate with full Name & Official Seal.
