Schedule- 12 (54)
(Relating to Rule 26)
License for itinerant sale
Serial No: Ref. No and Dispatch No:
Date:
1. Name and surname:
2. Father’s name:
3. Grand-father’s name:
4. Birth place:
5. Temporary address (including Ward No.):
6. Permanent address (including Ward No):
7. Name of food intended to be sold or distributed:
8. Signature:
9. Thumb impressions (only when one cannot sign) 55 :
10. Name of the other family members of who go to sell or distribute the food,
by taking the custody of license:
(a) … … … … …
(b) … … … … …
(c) … … … … …

_______________________
54 Inserted by Second Amendment.
55 Inserted by Fourth Amendment.

Signature of the licensing authority: …
Name of Municipality or Village Development
Committee: … …
District: … … … …
Zone: … … …
Signature and office seal falling also over the photograph.
License fee: Rs. … …