ANNEXURE - V

                                               .............................. Town Panchayat                  Here affix              
                                                                                                                        court fee
                                                                                                                        Stamp for Rs.2/-

 APPLICATION FOR LICENCE/RENEWAL OF LICENCE TO RUN TRADE NOTIFIED
AS DANGEROUS AND OFFENSIVE IN SCHEDULE V UNDER SECTION 249 OF THE
TAMIL NADU DISTRICT MUNICIPALITIES ACT, 1920.

To

The Executive Officer,

.......................Town Panchayat, 

Sir,

           I  request  that  a  licence may  be granted  to run.........................  (nature of trade) 
   from.... date in the under mentioned premises; 

1. Name of the applicant; 

2. Name of the father/husband 

3. Age 

4. Address (Door No. and name
   of the street) 

5. Details of premises for
   which licence is applied
   for:

   i) Door No. 

  ii) Street in which located 

 iii) Ward 

6.a) Name of the owner/proprietor
     of the premises with address 

  b) If the applicant is not the
     owner of the premises whether
     a letter of consent has been
     obtained from the owner and
     attached with the application
     to use the premises for the
     trade. (Note the name of
     trade or business. Applicant
     must be the owner of the
     trade)

7.  Purpose for which the premises
    is to be used/continued to be
    used the licence required.
    (Commercial or trade) 

8.  No. and date of licence of the
    previous year if obtained.

9.  The period from.........to
    .........for which now licence
     or renewal required. 

10. Monthly rent of the building/
      premises. 

11. No. and date of payment of
     licence fee:

 12. The name in which the licence
       has to be issued. 

13. Details of machineries if any
      installed in the premises.
      Give full details. 

    i) Order No. & date of Town
       Panchayat 

   ii) Resolution No. & Date of
      Town Panchayat

S.No.   Details of          Whether        Details of            Date of               Order No.&
           prime movers     run by           production          installa-              Date in
            with horse         steam,oil      machinery          tion  or               which
            power                 or elect-      run by               function               installation  
                                         ricity.      the prime           ing                      was origina-
                                                       mover                                          lly permit-
                                                                                                         ted by the
                                                                                                         Town Pt.

    I  agree to abide by the rules and  regulations of the Town Panchayat and Government to run the trade.

 Place:        

 Date:                                                                                      Signature of Applicant

ACKNOWLEDGEMENT

           Received  application          from  Thiru.....................for licence/renewal of
licence to conduct     trade    business      in  this office  on... ..................... He is
informed to  contact    the    Executive  Officer  on .......................(after 10  days)
regarding this  application.       His     application  has         been  registered  as
Sl.No.......... in the register maintained for this purpose.

                                                                                                     Executive Officer,

                                                                                           ................ Town Panchayat.