ULHASNAGAR MUNICIPAL CORPORATION CITIZEN FACILITATION CENTRE SUBJECT: RENEWAL OF ENGINEER / SUPERVISOR LICENSE Token Number (For Office Use) Date:- / / (If Citizen Identification Number is given, do not fill below Details) Applicant's Details: Last Name/ Surname Name Father/Husband's Name Details of Society (If Application from Society): Name Of Society: Designation Address: Head Information House/Building/Soc. Name: Flat/Block/Barrack No.: Wing/Floor: Road/Street/Lane: Area/Locality/Town/City: Taluka: Pin code: Ward Committee No.: 1 [ ] 2 [ ] 3 [ ] 4 [ ] Electrol Panel No.: Telephone No. (if any): Contact Person: Email Address (if any): Necessary Particulars about above service: Head Particulars 1 Type of License- (Tick [?] whichever applicable) [ ] Engineer License [ ] Supervisor License 1 [ ] Supervisor License 2 2 Original License No. 3 Expiry date of License Necessary Enclosures related to above application are enclosed as under. (If enclosed tick [ ? ] or not enclosed tick [?] ) Enclosures Yes/No 1 Original copy of license [ ] 2 Detailed information about Building Permissions, Plinth Completion Certificates and Completion Certificates obtailed during the last year. [ ] Citizen Identification Number Declaration I/We..................................................................................................state on solemn affirmation that the above information is true and correct with the best of my knowledge. If the information given is found wrong then I/We shall be held legally liable for its consequences. Date:- Applicant's Signature ( ) The document may please be delivered to:- 1. Self/Nominated Person [ ] a) C.F.C. [ ] b) Camp No. [ ] Name of Nominated Person (________________________________________________) 2. By Post a) U.P.C. [ ] b) Register A.D. [ ] 3. Courier [ ] (Not to be filled if address is same as above) Correspondence Address:- Last Name/ Surname Name Father/Husband Name House/Building/Soc. Name: Flat/Block/Barrack No.: Wing/Floor: Road/Street/Lane: Area/Locality/Town/City: Taluka: Pin code: Email Address (if any):
