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 number of house, mohalla,town or village police station and district........ .. ............................... .. 7. Complete address of place where PDS 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 licence in respect of PDS items issued to me under the provisions of the Essential Commodities Act,1955 or any order made thereunder was ever suspended or cancelled. I have carefully read the conditions of licence given in form 'B' appended in the Haryana Public Distribution System (Licensing and Control) Order,2002 and I agree to abide by them. *(a) I have not previously applied for such licence in any other district for PDS items *(b) I applied for such licence in other district namely...... for PDS items on....... ..and was/was not granted a licence. *(c) If yes No. of licence..................... *(d) I hereby apply for renewal of licence No...... dated.... issued to me on........... *Strike off clauses which are not applicable Place........... . Signature of the applicant Dated...........