Application for LPG Distributor Retail License

To
The Licensing Authority

Sir,

I hereby apply the grant of a licence under the Assam Trade Articles (L&C) order, 1982.

The required particulars are given here under:-

Applicants Particulars and Residential Address

Name *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

S/O *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

Age *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

Caste *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

Street Name 1 *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

Street Name 2

Village/Town *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

District *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

PIN code *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

Mobile Number *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

E-Mail

Other details

Name/Style which license is required *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

Situation of applications place of business

House/Shop No

Village/Town

Market

Section

Name of partners, if any of the firm

Sl.No

Name

Fathers Name

Age

Address

Contact No

Sl.No

Name

Fathers Name

Age

Address

Contact No

Particulars of trade articles in which the applicant wants to carry on business as a

Sl. No

As a wholesaler

As a Importer

As a Retailer

Sl. No

As a wholesaler

As a Importer

As a Retailer

Section

Did the applicants previously held a license appointment on appointment retailed for which license has now been applied for, if so given details of previous appointment.

i) Name of trade articles (s) :

ii) Licence no :

How long has the applicants been trading in the trade Articles for which the license has been applied for? :

Particulars regarding stocks of Trade Articles in possession on date or application. :

Complete address (with House no. market etc.) of godowns or place where trade articles for which licence has been applied will be stored

Village/Town

P.S

District

Pincode

Has the applicant ever been convicted by a court of law for contravention of any order issued under Essential Commodities Act, 1955 during last 3 years?

Particulars of suspension or cancellation of the licence held the applicant during last 3 years

Whether the applicant was declared or adjudged as an insolvent by a court ?

I declare that the particulars mentioned at item no. 1 to 13 above are true to the best of my knowledge and belief and nothing has been concealed therein. I have carefully read the provision of the Assam Trade Articles (Licensing and Control) order, 1982 and I Agree to abide by them.