FORM 12





[SEE RULE 154 (7)]



APPLICATION FOR GRANT OF A LICENCE FOR PUBLIC DISPLAY OF FIREWORK



I,………………., on behalf of ………………apply for a licence under the Explosives

Rules, 1983 for possession and use of Public Display Fireworks. The necessary particulars are given below and required documents are enclosed.

Replies to be given in this Column

1. Name in which licence is required to be granted (see note below).. .. ..

2. Age (see note below).. .. ..

3. Postal Address.

Pin code No.

Telephone No.

Telegraphic Address Telex.. .. ..

4. Qualification and experience of the applicant and competent persons employed by him.. .. ..

5. Name, qualifications and experience of the persons supervising the display .. .. ..

6. Description and quantity of fireworks to be used. ..

7. (a) From whom the fireworks will be obtained: Name Address Form and Licence No. held Validity of licence (b)Address and licence No. of the place where fireworks will be stocked.. .. .. .. … .. .. .. .. ..

8. Description and quantity of fireworks to be displayed

9. Time of display and address of the place where the &display will be held .. .. .. .. .. ..

10. (a) Has the applicant been convicted under any offences or ordered to execute any bond under Chapter Will of the Code of Criminal Procedure, 1973, during the last ten years? (b)If yes, give details? . . . Yes No

11. (a) Particulars of any licence under the Explosives Act ' 1884, and the rules framed thereunder held by the applicant during last ten years. (b) Was any licence cancelled/not renewed (c) If yes, give details . . . Yes No

12. Additional information if any.

I certify that the information given above is correct.

Date…………

Signature of applicant

(Authorised person in case of Company)…….

Place……….

Name in full……………

Address………………….

NOTE.-

(1) In case where application is made in the name of a company, the names and address of Directors and Partners and the name, address and specimen signature of person or persons authorised to sign correspondence in respect of licence applied for should be given on a separate sheet and enclosed with this application form.

Any change in the above information should be immediately communicated to the licensing authority and authority renewing the licence.

(2) Age to be given in case the applicant is an individual.

(3) Separate sheet may be attached if the space given in the form is not sufficient.