(Before filling the application please read the Note/Instruction given at the end of the application form) FORM 4 [See Rule 154(4)] APPLICATION FOR GRANT OF LICENCE TO POSSESS AND SELL EXPLOSIVES I,..................on behalf of ................. apply for grant of a licence for possession and sale of explosives. I give below full particulars and enclose other documents as required. 1. Name in which licence is : required to be granted Affix recent colour passport size photo duly attested by a Gazetted Officer 2. Status : Individual/Company/Society 3. Age : 4. Postal Address : Telephone Number : Qualification and experience of 5. applicant and the technical personnel employed by him (give individual details and attach separate sheet if required) : 6. Situation of premises (a) State: Puducherry (b) District: Puducherry (c) Town or Village : (d) Postal Address: (e) Nearest Police Station : 7. Explosives proposed to be possessed and sold : 8. Are the premises attached to a factory licensed to manufacture explosives? If so, give the licence No. : : 2 : 9. Have the premises previously been licensed? If yes Please give:: YES NO i) Previous licence Number : Sl. Name and Description Class Division if any Quantity No. At any one time in the month 1. Fireworks Class 7, Division2, SubDivision2. 50 Kgs. ii) Name and address of previous licence : iii) Reasons for cancellation/ Non renewal of previous Licence : 10. Has the applicant been convicted under any offence or ordered to execute any bond under chapter VIII of Cr.P.C, 1973, during the last 10 years? If yes, please give details : YES NO 11. (a) Particulars of other licence if any, under Explosives Act,1884 held during the last ten years : (b) Was any licence cancelled / not renewed? : YES NO (c) If yes, give details : 12. Details of additional information, if any : I hereby certify that the information given above is correct. Signature of the applicant (Authorized person in case of Company) enclose authorization letter Date : Full Name : Place : Address : NOTE/INSTRUCTIONS (a) Last date for submission of duly filled in application in the Office of the District Magistrate, Revenue Complex, Saram, Puducherry is 27.08.2008. (b) The premises shall have a floor area of minimum nine square meters. (c) The premises for storage of fireworks, safety fuse shall be at a distance of minimum 15 meters from any such premises or any other premises used for storage of similar explosives, flammable or hazardous materials. (d) Please attach the following to the application: (i) Application in Form4 (3 sets) (with passport size photo attached duly attested by Gazetted Officer in each application) (ii) Site plan (4 copies) drawn to scale certified by a Registered Engineer/ Architect. (iii) Two passport size photograph in addition to three pasted in the Form4. (iv) Rough location sketch (4 copies). (v) Two copies of the lease/rent agreement if the premise is taken on lease/rent. (vi) Two copies of the title deed if the premise is owned by the applicant. & (vii) Two copies of the consent letter from the owner of the premise for running cracker shop, if the premise is leased/rented.
