FORM IV
(See rule 18)
APPLICATION FOR RENEWAL OF LICENCE

SEAI,
From
Dr.............................
To
District Health Officer, …………………………… …………
Sir,
Subject: Renewal for Licence No …….. dated  …………
I request you to kindly renew my licence No ……….dated the………….. for the next 5 years.  I am providing the facilities as prescribed by the Act and the rules framed thereunder.  I have herewith attached a demand draft for Rs. 100 only.
Thanking you.
Yours faithfully
Signature…………
Name ……………
Place : ………..
Date : ………..