To The District Supply Officer, Trivandrum. SCHEDULE 21, FORM 'A' (See Clause 5 (1) KERALA PULSES DEALERS LICENSING ORDER 1972 Application for Grant/Renewal /Re-issue of Licence 1. Applicant's Name : 2. Applicant's profession : 3. Applicant's residence : 4. Situation of applicant's place of business with particul-: ars as to number of house, Street, Ward, Village or Town and District. 5. How long has the applicant hold a licence in pulses : been trading 6. Did the applicant hold a licence on any previous occas-: ion? If so, give the particulars including its suspension or cancellation. 7. Quantities of items of pulses handled during the last : three years. 8. Quantities of items of pulses likely tobe handled during: the current year. 9. The availability of finance for carrying on this trade : 10. Income-tax and sales-Tax paid by the applicant on the date of application (seperate figures are to be given for each items of Pulses) 11. Quantities of Pulses in the possession of the applicant : on the date of application (seperate figures are to be given for each items of Pulses) 12. Complete address of the applicant where the pulses is/ : are proposed to be stored. 13. Whether the applicant wants a licence, as a wholesale : or retail I declare that the quantites of Pulses specified above are in my possession this day and agree hold at the places noted above. I have carefully read the conditions of Licence given in Form 'B' appended to the Kerala Pulses Dealers Licensing Order 1972 and I agree to abide by them. a) I have applied for such licence in this District for . . . . .. . . . . . . . . . . . . . . and /was not granted licence on. . . . . . . . . . . . . b) I hereby apply for renewal of licence No. . . . . . . . . issued to me on . . . . . . . . c) I enclose a Treasury Receipt for Rs. . . . . . . . . . . vide Chalan No. . .. . . . . . . . Dt. . . . . . . . . being the fee for the renewal/Grant/Reissue of licence. Place: Date: SIGNATURE OF APPLICANT. STAMP
