"FORM 'N'" [See rule 21A(1)] Form of application for availing benefit under provisos to sub-clause (iv) of clause (f) of section 2 of the Act. Sir/Madam, I hereby apply in pursuance of sub-rule (1) of rule 21A of the Goa Entertainment Tax Rules, 1965, for availing benefit under provisos to sub-clause (iv) of clause (f) of section 2 of the Act. I agree to furnish such security as may be demanded by the Commissioner or any other notified Officer. I agree to furnish true returns of payment of admission and other details as required under the Goa Entertainment Tax Act, 1964 and Rules framed thereunder, within specified time. I agree to abide by the conditions to be imposed in the order granting the benefit hereby applied for. I give herebelow the details for consideration of my application: (1) Name of applicant (Proprietor): (2) Resident address with phone No., if any: (3) Kind of entertainments provided: (4) Place where they are held: (5) How often in a week and on what days: (6) Payment of admission (Give details of rate of tax): (7) Name of the permanent theatre where the facilities, safety measures and other maintenance items provided: (8) The existing facilities in the said cinema theatre (items are to be provided, attach separate sheet, if necessary: (9) Details of facilities, safety measure and other maintenance item proposed to be provided for in the said cinema theatre (attach separate sheet, if necessary): (10) An estimate of expenditure on the item covered by (9), duly certified by the Chartered Accountant: (11) Drawing plan of modifications to be done in the permanent cinema theatre (duly signed by competent authority): (12) A certificate stating the period within which project of providing facilities, safety measures and other maintenance items shall be completed (duly signed by competent person): (13) An undertaking jointly signed by the lessor/owner and the proprietor stating that the amount of service charges collected shall be spent towards maintenance and providing facilities and safety measures on or before....... and in the event of default, they shall be jointly and severally liable to pay the amount of such service charges collected with penalty levied. A copy of the licence issued under the Cinematograph Act is also submitted herewith. Place: Date: Signature of Proprietor List of Enclosures: 1) 2) 3) 4)
