FORM 'A' [See Rule 3 (1) and 8 ] ( Application for Licence/ renewal ) 1. Name of applicant for license :- ( in full) 2. Profession:- 3. Full Address 4. Father's name in full ( in case of firm, give names and address of partners and person holding powers of attorney to act on behalf of the firm). 5. Specific place or places of business 6. Financial status with details of persons i.e. property, annual Payment of income tax and any other relevant evidence regarding financial status 7. Specific purpose for which license is applied for (Processing/storing/selling/trading) 8. Name of the mineral/ore for which license is required. 9 Evidence of payment of application fee 10. Name & address of persons/firms from whom the mineral/ores will be purchased/procured 11. Period for which license is required 12. In case of renewal the number and date of original license 13. Detail of income tax/Sales tax clearance Certificate. 14. Any special ground for grant of license in favour of the applicant List of enclosures DECLARATION I/we hereby declare that/we have and understood all the provisions of the Orissa Mineral(Prevention of theft, smuggling and other unlawful Activities) Act,1989 and Rules made thereunder and the conditions of the licence and, I/we to abide by the same. Date of application Signature of the Applicant Place
