1. Name in which license is required to be grant replies to be written in this column 2. Status:- Individual/ Company Society:- 3. Age ( See notes below) 4. Postal address: 5.Qualification and experience of applicant and the technical per annum employed, by him (give individual details and attach separate sheets if required):- 6. Situation of premises for storage:- Survey No. 7. Explosive proposed to be stored for use. 8. Whether the premises previously licensed? If yes, please give(i) Previous License No Individual CompanyIon behalfapply for grant of license/amendment oflicense Noto possess explosive for use.The required particulars are given below and thenecessary documents are enclosed. SocietyAgeState:- District:-Town or village:- steamer ghatPolice stationRailway stationSl.NoName & DescriptionYes NoAPPLICATION FOR GRANT OR AMENDMENT OF LICENSE TO POSSESS Form - 5 (See Rule- 154 (4) and 154 (5) EXPLOSIVE FOR OWN USEGovernment of OrissaIndustries DepartmentPublished on National Portal of India (india.gov.in) Class Division One time Quantity if any 13. License No. of road Van, if used. 14. Has the applicant been convicted under any offence or ordered to execute any bond under chapter VIII of code of criminal procedure,1973 during the last 10 years, if yes, give details. 15. (a) Particulars of other license if any under explosives act,1984 held by the applicant during the last 10 years. 12. Mode of transport of explosives 9. Explosive proposed to be used per day Name and description Class Division Quantity 10. Details of site where explosive will be used. 11. Distance of site where the explosive will be used from the storage premises mentioned in item No.6 (iii)Reasons for cancellation/non-renewal of previous license (b) Was any license cancelled/ not renewed ? Yes No NoYes(c) If yes, give details. 16. Details of amendment proposed/ additional information, if any. I hereby certify that the information given above is correct. Date: Signature of the applicant Full name and address. Published on National Portal of India (india.gov.in) YesNo(ii)Name and address of the previous licensee
