FORM FL-A-10

(See Rule 42 A (1))

Application form for sale of Beer Wine in Sealed Bottle
Name and address of the
1
applicant
Name and address of the partner
2
if any
Proposed premises name and
3
complete address
Whether the applicant hold
license for the sale of Mild liquor
4
or IMFL,
if yes details
Whether the applicant hold
5 separate godwon for storage of
liquor
Whether Security deposit of
6 equals to 100% of licence fee is
deposited
Whether licence was cancelled or
suspended by Police dept, State
7 Excise or corporation, if yes,
give
detail
Whether application is defaulter
of Land & revenue , Sale Tax,
8
Income Tax or any goverment
Dept
Proof regarding solvency
9
certificate

Signature of
applicant

Date
Place

To,
The Collector
(State Excise Deparmtent

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List of document required for Grant of FLBR-II Licence

1. Application in prescribed format
2. Application Fee vide challan of Rs. 100/-
3. (3) copies (Blue print) map of proposed Licensed premises.
4. Certificate of legality of structure from concerned department
5. No dues with Sales Tax / Income Tax department Affidavit
6. Leave License copy of proposed licence premises
7. Affidavits regarding No Excise Schedule Licence in the name of
proposed licensee
8. Rent receipt of premises from concerned department
9. Shop & Establishment licence
10. Concerned department Tax receipt
11. NOC of Land lords / Society to sell beer in the premises
12. Bank Guarantee 100% of licence fee
13. Proposed premises should be minimum 180 Sq.Foot
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Action taken by the Excise Department
14. Police Verification / character certificate
15. Department Inspectors / Sub Inspectors Report
16. Applicant statement record in presence of Officer of State Excise
17. concerned department report regarding legality of structure / No
action pending against the proposed premises
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After approval by the committee under the chairmanship of Collector
18. 25% of the licence for FL-3 i.e Licence fee for FLBR-II,
19. Security Deposit of Rs 10,000/-
20. Applicants 3 Passport size Photos