1. FORM – I
FORM OF APPLICATION FOR LICENSE / RENEWAL OF LICENSE TO
MANUFACTURE FOR SALE/ SELL/ STORAGE FOR SALE/ DISTRIBUTION OF
WHOLESALE/ RETAIL
TO
THE LICENCE AUTHORITY/
LOCAL (HEALTH) AUTHORITY
I / We ____________________________________________ Son/ Daughter/ Wife of
______________________________ aged _____ sex ______ Residing at
____________________________________________________________________ by
occupation____________________________________________________________
apply for a fresh license/ renewal of license under the provisions of the PFA Act 1954
and rules made thereunder for the manufacture for sale/ sell/ storage for sale/
distribution in wholesale/ retail ____________ per day within the limits of local area of
the license authority/ authorities of _________________________________________
in the premises situated at ______________________ from the shop.
2. Class of articles of food for which a license is prayed for
_____________________________________________________________________
3. I/ We shall abide by the provisions of the PFA Act 1954 and the rules made
thereunder and carry on the aforesaid trade subject to the restrictions and conditions
imposed by the license granted to me/ us.
4. I/ We are enclosing herewith medical certificates(s) in Form -III of my own/ our own
and also that my/ our employee/ employees.
5. The amount of Rs. _________ is remitted/ credited to Government under the Head of
account “0210 – Medical and Public Health, 04 – Public Health, 104 – Fees, fines etc.,
under PFA Act.
6. In my/ our absence Shri/ Smt. ____________________________________
Age_________Sex_______,Resident of
__________________________________shall conduct the aforesaid business.
7. The statements made above are true to the best of my/ our knowledge and belief, and
if anything is found to be false or not true the license shall be liable to be suspended,
canelled or forfeited.
Note:-
In case of Partnership or Limited company or Co-operative Society attested copy of
Partnership deed or article of association or Registration certificate issued by the
Registrar of Co-operative Society, as the case may be shall accompany the application.
Dated: SIGNATURE OF THE APPLICANT
Specimen Signature of the Applicant :
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