CHECK MEMO FOR SHIFTING OF A4 SHOP

1.

Name of the A4 shop

2.

Gazette Serial Number

3.

Date of issue of license

4.

No. of times the A4 shops has shifted

during the Excise Year

5.

Reasons for shifting

5.1

Do rules support the reason given

S.
No.

Ingredients

Satisfied
(Yes /No)

5.2

Are the reasons genuine. If yes,

furnish the documents (e.g. road
widening, income tax return, VAT
turnover)

5.3

Give the analysis of the submitted

documents

6.

Have they received any objections

from other A4 shop licensee / the
public/the residents of that locality

If yes, have they been examined

thoroughly

Has the District Collector

recommended the shifting of
premises

How Satisfied

1.

6.1
7.

8
.

Furnish the details of A4 shop with turnovers functioning within the municipality /
mandal.

8.1

8.2.

The distance between the

existing and the proposed
premises
Is there any notified A4 shop in
the locality / ward to where the
shop is proposed for shifting

9.

9.1

If there any unserved demand at

the locality / area to where the
A4 shop is proposed for shifting
(explain in detail)

Demand Analysis

Population:
Consumption during Excise year
: (7/2014 to 2/2014)
Per capita consumption:
Per capita consumption of
district :
Comments of DC on above
10.

Is the proposed premises in

accordance with Rule 25.

---------

___________ (Kurnool Excise District)

Ward No.1

Nandikotk
ur

IML cases
Percapita
consumpti
on

11.
S. No.

Ingredients

Satisfied (Yes /No)

How Satisfied

Prohibition & Excise Inspector,