FORM L. AG. A. (PSV) [See Rule 142 (5)] Form of application for an Agent's License To, Director of Transport/Assistance Director of Transport. In accordance with the provisions of sub-section (1) of section 93 of the Motor Vehicles Act, 1988. I, the unsersigned, hereby apply for a license to work as an Agent for Sale of Tickets to the passengers of public Service in the State of Goa. 1. Full Name ___________________________________________________________ (Surname) (Name) (Father's Husband's Name) 2. Age _________________ 3. Full Present Address: H.No. _____________________________ Pin _____________ 4. Permanent Address ____________________________________________________ H.No. _____________ Road/Lane ____________ Name of Locality _____________ City/Town ___________________ Pin _____________ 5. Educational Qualification _______________________________________________ 6. Have not previously held have previously held an agents's license issued by an agents's license and that it/was not suspended/cancelled/renewed. 7. I hereby declare that I am not less than 18 years of age and that the above statements are true. I attach two copies of a recent photograph of myself. Signature of applicant Duplicate Signature Dated _______________ 200_______ 8. Full description of the place where the vusiness is to be carried on _______________ (a) Location, open area, covered area for Office and Storage (State full details-house, godown, numbers, lane or by lane, main godown, numbers, lane or by lane, main road and Postal District). (b) (I) Area available for parking vehicles while being loaded or unloaded. (ii) Area available for parking while waiting for loading or unloading or turn. (c) Facility available for loading and unloading and storage. (d) Particulars of weighing device provided. (e) Any other particulars. 9. I am fully, conversant with the conditions of goods carrier's permit and the provisions of Motors Vehicles Act, 1988 and the rules made thereunder so far as they relate to plying of goods vehicles for hire and duties and function of an agent. 10. I hereby declare that to the best of my knowledge and belief the particulars given are Correct and true. Place: Date: Signature of Applicant. Strike out whichever is not applicable Please pay the cost of this form at the concerned RTO Rs. 10.00 Printed from www.goatransport.com.
