(If Citizen Identification Number is given, do not fill below Details) Applicant's Details: Father/Husband's Name Details of Society (If Applicatio n 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) Necessary Particulars about above service: Particulars License Number Name of the License Holder Name of the Business Necessary Enclosures related to above application are enclosed as under. (If enclosed tick [ 9 ] or not enclosed tick [U] ) Yes/No Succession Certificate given by the competent court [ ] 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):
