(See Rule 4)



        The Municipal/Corporation Commissioner/ The Executive Officer...................Panchayat
        I hereby apply for the grant of permission for the Construction/Reconstruction/ Location of a Permanent/Temporary/Cinema my favour, and give the details as follows:

(Signature of the Applicant)

  1. Full name of the applicant :
  2. Father's/Husband's name and occupation :
  3. Permanent address of the applicant:
    1. Village
    2. Panchayat/Municipality/Corporation
    3. Taluk                         Ward
    4. District
  4. Present Occupation of the applicant :
  5. Status, antecedents and previous experience of the applicant :
    Note:- The applicant should furnish herein among other things, particulars of taxes or other dues to Government and whether, in respect of any assessment for tax, the matter is under consideration of the Government.
  6. Is the application for :

    1. Permanent cinema
    2. Temporary cinema
  7. Place where the cinema is proposed to be located :

    1. Survey No.
    2. Village:                        Ward:
    3. Taluk:
    4. District:
  8. Site plan drawn to a scale of not less than 1cm. to 15 metres covering an area up to 100 metres from the boundaries of the proposed site, showing:

    1. the position of the proposed premises in relation to any adjacent premises and to the public through fare upon which the site of such premises abuts; and
    2. thatched sheds, if any, in the neighborhood;
    3. The surrounding Roads and Buildings, the distance of all Educational Institutions, Hospitals,Temples,Mosques, Churches or other places of Public Worship.
  9. If the land/site is not owned by the applicant:
    1. Name and address of the owner:
    2. Is documents to prove the lawful occupation of the applicant enclosed.
  10. Is the applicant in possession of other places licensed under the Act ? If any:
    1. (a) Whether in the same locality or elsewhere
    2. whether at the time applying for licence or any previous time.
  11. Is the following attached to the application?
    [Treasury receipt for payment of fee for permission under rule 19(1)]
  12. Distance, by public road, of the proposed site, to the:

    1. nearest permanent cinema:
    2. nearest temporary cinema:
    3. nearest educational institution:
    4. nearest temple or other religious institution:
  13. Interest of the Public generally, likely to be served by the location of the Cinema.
  14. Suitability of the place where the cinema exhibitions are proposed to be given.
  15. Adequacy of the existing place for the exhibition of cinema, films in the locality.
  16. Population of the place according to [he latest census figures.

Place:                                                                                          (Signature of the applicant)