FORM NO: "B" APPLICATION FORM FOR LICENCE/RENEWAL OF LICENCE AS A RETAIL DEALERS IN KEROSENE (See Clause 11 (1) of the Kerala Kerosene Control Order, 1968) 1. Applicant's Name and address : 2. Applicant's place of business : 3. Whether the applicant has been trading : in Kerosene and if so, for what period. 4. Whether the applicant is for : 1) New Licence : 2) Renewal of Licence : 3) No. and date of existing/Licence : 5. Whether the applicant is a retail dealer : under the Scheme of Rationing if so, give furnish the authorisation number and date 6. Number and date of Chalan and Name : of treasury into which licence fee for Rs..................../-has been remitted (attached chalan in original) 7. Details of place where Kerosene is : proposed to be stored I declare that the following quantities of Kerosene are in my possession this day, and are held at the place noted against them. Name of Place : Stocks : Variety : Quantity (In litres) : I certify that the best of my knowledge the particulars given in the application are true and correct. I also agree to comply the all directions issued by the Government, the District Collector or any officer of the Civil Supplies Department not below the rank of Rationing Inspector from time to time to regard to the purchase or the sale or the Storage of Kerosene. Place : Signature of Applicant Date :
