Application Form for License for collection, transport and disposal of excreta

Refer to Document Content for full form details. (See Regulation –5) To, 1. Name of the applicant: Shri/Ms___________________________________ 2. Nationality: Indian______________________Other_______________ 3. Address: Regd. Office:_________________________________________ Head office:___________________________________________________ 4. Telephone No.: (O)_________Mobile No.____________Email ID________ 5. Registration No. of Vehicle:____________________________________ 6. Pollution Certificate of the Vehicle valid up to:_______________________ 7. Insurance of the Vehicle valid up to:_______________________________ 8. Fitness of the Vehicle valid up to:__________________________________ 9. Vehicle, whether fitted with GPS:_________________________________ 10. Details of the vehicles indicating leak proof, odour and spill proof having proper vacuum/ suction and discharging arrangement (Document proof of any may be enclosed). 11. Processing fee for License Rs. (As prescribed by Delhi Jal Board) D.D. No._____________Date_____________Bank____________________ I/We certify that information given by me/us in column 1 to 11 are true to the best of my knowledge and belief. I also certify that I have read and understood the attached terms and conditions 1 to 13 and agree to abide by them. I agree that if any information given by me is found wrong the application for License will be liable for cancellation at any time. Signature(s) of applicant(s) Date: __________________ No. of document attached: _______________ PASTE PHOTO (SELF ATTESTED)