PHOTO

PART-1 ATTESTED BY
SERVING G.O.

1. Name of News Paper/Magazine_________________________________

2. Language of Publication _________________________________

3. Periodicity of the Publication ________________________________

4. Name of the applicant _________________________________

(a) Nationality _________________________________

(b) Father’s Name _______________________________

(c) Residential Address with P.S. _________________________________

[Attach proof – attested by G.O]

_______________________________

_________________________________

5. Name of the owner/Proprietor of the title______________________________

(a) Nationality _________________________________

(b) Father’s Name _________________________________

(c) Residential Address with P.S. _________________________________

[Attach proof – attested by G.O]

 _________________________________

_________________________________

6. Name of the Publisher _________________________________

(a) Nationality _________________________________

(b) Father’s Name _________________________________

(c) Residential Address with P.S. _________________________________

[Attach proof – attested by G.O]

_________________________________

_________________________________

7. Place of Publication with full address __________________________________

(Police Station)

[Attach proof – attested by G.O] _________________________________

_________________________________

8. Name of the Printer _________________________________

(a) Nationality _________________________________

 (b) Father’s Name _________________________________

(c) Residential Address with P.S. _________________________________

[Attach proof – attested by G.O]

_________________________________

_________________________________

9. Name of Editor _________________________________

(a) Nationality _________________________________

(b) Father’s Name _________________________________

(c) Residential Address with P.S. __ _______________________________

[Attach proof – attested by G.O]

_________________________________

_________________________________

10. Name of the Printing Press, Address _________________________________

with P.S.

(Attach proof-attested by G.O.) _________________________________

_________________________________

11. Details of proposed financial

investment in the newspaper:

 (i) with FDI/FII _________________________________

(attach approval copy of Ministry

of Information & Broadcasting) _________________________________

(ii) without foreign collaboration _________________________________

12. Please state whether the owner owns _________________________________

any other newspaper/magazine and if so,

its name, periodicity, language and _________________________________

place of publication. _________________________________

13. Policy to be pursued by the paper __________________________________

14. Whether the applicant is facing any __________________________________

criminal proceeding or ever convicted?

If so, give details. __________________________________

__________________________________

15. Pan No. of the applicant. __________________________________

16. Telephone No.(s) of the applicant ___________________________________

17. E mail ID No., if any. ___________________________________

Note:- It is certified that above title(s) is/are not being used by any
Government/Semi Government Department to the best of my
knowledge. It is also certified that above title (s) does not fall under
Copy Right Act.

Signature of the applicant

Date____________