CosL:

lC8M - A
(SecLlon - 4 and rule-4)
Iorm of App||cat|on for Money Lend|ng L|cense
1) AppllcaLlon for : Money Lendlng
2) name of AppllcanL :
3) laLher name :
4) Cender :
3) 8ellglon :
6) naLlonallLy :
7) CasLe CaLegory :
8) 8esldenLlal Address :
uoor number : SLreeL :
LocaLlon : vlllage :
9) Shop Address
uoor number : SLreeL :
LocaLlon : vlllage :
ln Code :
10) roof of Address :
11) lf appllcanL ls naLlve of an lndlan sLaLe
a) lull address ln such lndlan sLaLe :

b) A llsL of properLles owned ln such sLaLe :

12) Address of shop or place of buslness ln
8especL of whlch Lhe llcense ls applled for any
SubsequenL change should be noLlfled before
Cne monLh prlor Lo change of premlses :
13) lf Lhe appllcanL has more Lhan one shop or
lace of buslness, Lhe address of each shop or
lace of buslness :
14) Pas Lhe appllcanL applled for a separaLe
Llcense ln respecL of each shop or place of
8uslness menLloned agalnsL lLem no 7, lf so
wlLh whaL resulL? :
13) lf Lhe presenL appllcaLlon Made for granL of
new llcense :
16) 1he flnanclal year for whlch Lhe llcense ls
Applled for :
17) lee pald parLlculars
Challan no : Challan uaLe :
Challan AmounL : 8ank & 8ranch :

l solemnly and slncerely afflrm and declare LhaL Lhe parLlculars sLaLed above are correcL Lo Lhe besL of
knowledge and bellef, lf lL were found false on a laLer daLe, l wlll be llable for any consequences accordlng
Lo law and rules framed ln Lhls acL.

SlgnaLure of Lhe AppllcanL