SCHEDULE - III

FORM 'A'
[See Clause II (i)]

THE KERALA HYDROGENATED VEGETABLE OILS (VANASPATI) AND

BABY FOOD DEALERS LICENSING ORDER, 1975.

APPLICATION FOR GRANT/RENEWAL/REISSUE OF LICENSE.

1. Applicant's Name :

2. Applicant's profession :

3. Applicant's residence :

4. Situation of applicant's place of

business with particulars as to
No. of house, Street and Ward,
Town or Village and District.

5. How long has the applicant

been trading in notified
foodstuffs.

6. Did the applicant hold a notified

foodstuffs license on any
previous occasion? (If so give
particulars including its
suspension or cancellation if
any)

7. Quantities of each item of

notified foodstuffs handled
annually during the last three
years.

8. Quantity of notified foodstuffs

likely to be handled during the
current year.

9. The availability of finance for

carrying on this trade.

10. Income Tax and Sales tax paid

in the two years preceding the
year of application (to be
indicated separately for each tax
for each year).
 1.

2.

11. a) Quantity of notified

foodstuffs in the possession
of the applicant on the date
of application (separate
figures are to be given for
each item of notified
foodstuffs)

b) Compete address of place

where notified foodstuffs
are proposed to be stored.

12. Whether the applicant wants a

license as a wholesaler or
retailer.

I.declare that the quantities of notified foodstuffs specified above are in my

possession on this day and are held at the places noted above.

I have carefully read the conditions of license given in form 'B' appended to
the Kerala Hydrogenated vegetable oils (Vanaspati) and Babyfood Dealers
(Licensing Order, 1975 and I agree to abide by them.

a) I have not previously applied for such license in this district for notified
foodstuffs.

b) I applied for such licenses in this District for …………………… on

……………………. and was/was not granted a license on …………………

c) I hereby apply for renewal of license No. …………………. issued on me on

…………………..

(Strike off the clause not applicable)

Place :

Date :
Signature of applicant.