Form AE-3

(See rule 113 of the Explosives Rules, 2008) Application for approval or grant or amendment or transfer of licence for
possession and sale of explosives; for possession and use of explosives; or for possession of fireworks or safety fuse in a store house
I,..on behalf of.apply for approval or grant or amendment(1) of licence for the following purpose. 1. Purpopse: (Write the purpose corresponding to particular article as per Schedule IV, Part 1) . .. 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 (c)Age
(2) (1)

(d) Postal address:

.City .. DistrictStatePin code...

Police Station Railway Station / Steamer Ghat.

PhoneE-mail..Fax 3. The proposed premises are situated at the following address: Survey number .City .. DistrictStatePin code...
Police Station Railway Station / Steamer Ghat.

PhoneE-mail..Fax

4.

Qualifications and experience of applicant And the technical personnel employed by him. (Give individual details and attach separate sheet if required)

. . . .

5. (a) Explosives proposed to be possessed and sold:* Name and Class Description i. ii. iii . iv. v. vi. Division if any Quantity at any one time In one month

(b) Are the premises attached to a factory licensed to manufacture explosives? If so, please give the licence number .. 6. (a) Explosives proposed to be possessed and used* Name and Class Description Division if Quantity any To be To be used To be used possessed per day in one at any month one time

i. ii. iii . iv. v. vi.

(b) Details of site where explosives will be used .. (c ) Whether the site is coming under the Mines Act,1952:.. (If yes,documentary evidence to be submitted ; if not, particulars of proposed activity, documentary evidence and shot firer employed to be furnished) (d) List of documents attached with reference to clause (c) above (i) (ii). (iii)

(e) Distance of site where the explosives will be used from the storage premises mentioned in item 6 (f) Mode of transport of explosives (g) Licence particulars. of road van, if used ..

.. ..

7. Has the applicant been convicted under any offence . or ordered to execute bond under Chapter VIII of . Code of Criminal Procedure, 1973, during the last . 10 years. If yes, please give details. 8.(a) particulars of other licenses under .. Explosives Act, 1884, if any held by .. the applicant during the last 10 years YesNo... (b) was any licence cancelled or not renewed? .. (c ) If yes, give details .. I hereby certify that the above particulars given by me are correct. Date.. Signature of applicant.. (Authorised person in case of a Company) Full Name .. Address ..

*strikeout inapplicable portion Notes: Please see the rule for the purpose and documents to be enclosed (1) In case where application is made by a person other than an individual, the names and addresses of the occupier as per rule 2 and directors or partners or members, as the case may be, and specimen signatures of authorised person to be attached. (2)Passport size photographs of the occupier to be attached. (3)Any change in the above information should be immediately communicated to the licensing authority and authority renewing the licence. (4) Age to be given in case the applicant is an individual. Statutory Warning: Mishandling and misuse of explosives shall constitute serious criminal offence
under the law.

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