Form - 5 (See Rule- 154 (4) and 154 (5) APPLICATION FOR GRANT OR AMENDMENT OF LICENSE TO POSSESS EXPLOSIVE FOR USE I ........on behalf......apply for grant of license/ amendment of license No.... to possess explosive for use.The required particulars are given below and the necessary documents are enclosed. 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:- State:- District:- Town or village:- Survey No. Police station:- Railway station or steamer ghat 7. Explosive proposed to be stored for use. Sl.No. Name & Description Class/ Division one time Quantity if any ` 8. Whether the premises previously Yes No licensed? If yes, please give (i) Previous License No. ..... (ii)Name and address of the previous licensee ... (iii)Reasons for cancellation/ non-renewal of previous license ... 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 12. Mode of transport of explosives 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. (b) Was any license cancelled/ not renewed ? Yes No (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.
