Government of West Bengal
Public Works Department
Common Service Branch
Khadya Bhawan, Kol-87
APPLICATION FORM FOR RENEWAL OF LICENCE FOR GOVT. PREMISES
To,
The Assistant Secretary-II, PWD
&
Competent Authority under the West Bengal
Govt. Premises (Regulation of Occupancy) Act, 1984.
Sir,
I am in occupation of Govt. premises namely Flat/Quarter/Menial Room No. ............... at
..................................................................................................................................................(name of premises) having
Licence No....................... Date: ........................... under section 4 of the West Bengal Premises (Regulation of Occupancy)
Act, 1984. The Licence/Renewal expires on ..................................... (copy enclosed).
I pray that my licence may kindly be renewed for a further period of three years /up to the date of retirement on
superannuation with effect from..........................................................
I have read and understood the provisions of the aforesaid Act and I know that I shall abide by the terms and
conditions mentioned in schedule-I to the Act and such other terms and conditions as may be stipulated by the competent
Authority.
I hereby declare that I do not possess any house/flat/residential accommodation either in my own name or in the
name of any of the dependent members of my family within the local limits of Kolkata/Bidhannagar Municipal
Corporation.
I furnish all relevant particulars below attached for consideration of my application:
1. Name of the Applicant:
2. Designation of the post I hold:
3. Headquarters of the post I hold:
4. Department/Directorate/Office
to which the post is attached:
5. Date of joining the post:
7. Scale of Pay:
(i)Present basic pay including special pay, if any:
(ii)Dearness Allowance:
8. Date of birth according to service book:
9. Date of retirement according to service book:
10. Designation of Drawing & Disbursing Officer:
11. Name & Address of Treasury:
12. a. Spouse Name:
b. If the spouse is a Govt. Employee, his/ her Designation & Department:
Counter Signature of D.D.O./
Head of Deptt./ Head of Office
with Official seal.
Yours faithfully,
Full signature of the Applicant
Contact i) Mobile No.
ii) Office No.
iii) E-mail:
** He/ She is requested to attach copies of the original licence and recent pay slip with this form.
