(If Citizen Identification Number is given, do not fill below Details) Applicant's Details: Father/Husband's Name Details of Society (If Application from Society): Name Of Society: Designation Address: Information House/Building/Soc. Name: Wing/Floor: Road/Street/Lane: Taluka: Pin code: Ward Committee No.: 1 [ ] 2 [ ] 3 [ ] 4 [ ] Electrol Panel No.: Contact Person: Email Address (if any): Information of Property: Information Type of Property (Please Tick [9] as applicable) [ ] Land [ ] Building Property Number (Computerized) Town/City: Taluka: Survey/Block/Barrack No.: C.T.S. No.: Part No./Sheet No.: Plot No./Unit No.: Area of Land (sq.ft.) Road/Street/Lane: Ward Committee No.: 1 [ ] 2 [ ] 3 [ ] 4 [ ] Necessary Particulars about above service: Necessary Enclosures related to above application are enclosed as under. (If enclosed tick [9 ] or not enclosed tick [U] ) Not Applicable Copy of the construction completion certificate / usage permission along with approved map [ ] [ ] [ ] Consent letter (Any one of the following) a. Proof showing that the applicant is owner of the business place OR b. No objection certificate from Owner on Rs.20/- Stamp Paper, (If the applicant is tenant) [ ] OR [ ] [ ] [ ] Copy of a Ration Card before 01.01.95 Or Photo Pass of the applicant, if applicant is from protected Slum Dwellers Under Maharashtra Slum Development Policy 1971. [ ] [ ] [ ] Internal map of business place [ ] [ ] [ ] Location Map [ ] [ ] [ ] NOC from Fire Brigade [ ] [ ] [ ] Indemnity bond in specified format on stamp paper of Rs. 20/- [ ] [ ] [ ] Copy of Profession Tax registration certificate [ ] [ ] [ ] Copy of Registration Deed, for the partnership firm [ ] [ ] [ ] Shop & Establishment License [ ] [ ] [ ] Copy of the agreement and allotment letter of Gala issued by the Corporation [ ] [ ] [ ] Copy of License given as per Explosive Act [ ] [ ] [ ] Copy of License given as per Petrolium Act [ ] [ ] [ ] Declaration I/We ................................................................................................... state on solemn affirmation that the above information is true and correct to the best of my/our 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 deliverd 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: Father/Husband Name House/Building/Soc. Name: Wing/Floor: Road/Street/Lane: Taluka: Pin code: Email Address (if any):
