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F of apply for approval or grant or amendment of licence for the following purpose. 1. Purpose: (Write the purpose corresponding to particular article as per Schedule IV, Part I) 2. Name : I require licence in the following name and postal address: a) Name in which licence is required to be granted (see notes below) b) Status(1) c) Age(2) d) Postal address : City District State Police Station Pin Code Railway Station/Steamer Ghat E-Mail Phone Fax 3. The proposed premises are situated.

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