SCHEDULE –I

APPLICATION FORM FOR PREMISES LICENCE FOR BROWSING CENTER

From

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To

The Commissioner of Police,

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Respected Sir,
Sub: Application for the grant of premises/performance licence for Browsing Center
providing Services of Internet/internet connectivity in a public place.
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I ________________________________________________, Proprietor of
_______________________________________ under Section 34(1) of the Tamil Nadu City Police
Act, 1888) definition of public place, by name ____________________________________________
apply for grant of premises/licence at the following address. The place belongs to me/us taken on
rent is on lease/leave and licence.

1. Full Name of Applicant Owner :

2. Address :

3. Telephone Numbers(s) : LL:

Mobile:
4. Fax :

5. E-Mail :

6. Profession :

7. Nationality :
 :2:
8. Date of Birth :

9. Name of the Center :

10. Address of Browsing Center or, if at more :

than one location, of each location, use
separate sheet if necessary)

11. Jurisdictional Police Station :

12. Other name, if any, of the establishment :

13. Whether premise are owned, leased, rented :

or taken on leave and licence by applicant-
owner?(Specify)

14. If on rental, lease or leave and licence, :

period of tenancy/lease/licence

15. Approximate Sq.ft area of premises :

16. Telephone numbers at the browsing center :

with the name and address of the
Telephone subscriber (Use separate sheet if
necessary)

17. E-mail address of the browsing center :

18. Exact Nature of activities at the browsing :

center - attach separate Sheet if required)
(eg. Also serving Beverage and Snacks etc)

19. Name and address of conductor or operator :

of Browsing Center if other than applicant –
owner

20. Number of branches with address and :

telephone numbers

21. Whether a similar licence has been applied :

for, if so, give details

Signature of Applicant