SCHEDULE- III

FORM A- 1
(for Individuals)
Form of Application for an Arms Licence in Form II, III and IV

Application Form A-1 for grant of new arms license

DISTRICT MAGISTRATE SIWAN

A. PERSONAL DETAIL(S)
REFERENCE NO.: 05205A186D120

1. APPLICANT NAME MANORANJAN OJHA

2. PARENT/SPOUSE BALIRAM OJHA

3. GENDER MALE

Country State
Country District
4. PLACE OF BIRTH
INDIA BIHAR SIWAN

5. DATE OF BIRTH 01/05/1968

6. PAN NO XXXXXX698M

7. PRESENT ADDRESS
RATANPURA

SIWAN BIHAR
7/11/20 12:00 AM

8. TELEPHONE NUMBER

Office Residence

9.0 MOBILE NUMBER 7878079111

10 NEAREST POLICE STATION

null
RATANPURA
11 PERMANENT ADDRESS
ONLINE REG DATE :

SIWAN BIHAR

12 NEAREST POLICE STATION

13 OCCUPATION PROFESSIONAL

14 OFFICE/BUSINESS ADDRESS

Note – Nearest Police Station means the police station under whose jurisdiction the place given in the address

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 B. Other particular

16. Whether the applicant has been –

REFERENCE NO.: 05205A186D120

(a) Convicted
NO

ordered to execute a bond under

Chapter VIII of Code of Criminal
(b) Procedure, 1973 (2 of 1974) for
keeping the peace or for good NO
behavior

(c) prohibited under the Arms Act,

1959, or any other law from having
the arms or ammunition NO

17. Whether –

(a) the applicant applied for a licence

before- if so, when, to whom and
with what result NO

(b) the applicant’s licence was ever

suspended or cancelled / revoked -
NO

any other member of the applicant’s

(c) family is in possession of any arms
licence, if so, particulars NO

(d)
the applicant has a safe place to keep
NO
the arms and

(e) Additional particulars if the licence

is required for crop protection under
rule 33 NO

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 C. Particulars of Licence being applied for

18. Need for licence SELF PROTECTION

05205A186D120

Description of Arms for Weapon Description PERMISSIBLE

19. which licence is being
sought
Weapon Description HANDGUN REVOLVER OR PISTOL

20. Description of Ammunition

or Ingredients of
Ammunition for which PISTOL
REFERENCE NO.:

licence is being sought

Area within which applicant

21. wishes to carry arms ALL INDIA

Claims for special

22. consideration for obtaining I AM HEALTH SAFETY SECURITY AND ENVIRONMENT MANAGER
the licence, if any

D. Additional Information

23. Details for an application for licence in Form IV

(a) Place or area for which the

licence is sought NOT APPLICABLE

(b) Specification of the wild

beasts which are permitted to
be destroyed as per the NOT APPLICABLE
permit granted under the Wild
life (Protection) Act, 1972 to
the applicant

Name and description of any

member of the applicant’s
(c) family or servant employed
to watch crops or cattle
residing with him, by whom
the arms or ammunition
covered by this licence may
also be

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Declaration:
I hereby declare that the above particulars given in the application are true, complete and correct to the best of my
knowledge and belief. I understand that in the event of any information being found false or incorrect at any stage, I am
liable to be proceeded against and action taken under the relevant provisions of the Arms Act, 1959, the Arms Rules, 1962,
and other central enactments or the law for the time being in force.

Date: 11-Jul-20

Place: SIWAN
BIHAR Signature /Thumb - impression of applicant

Warning:
Suppression of any factual information or furnishing of any false or wrong information in the Application Form in violation of arms rules
will render the applicant liable for punishment under Section 30 of the Arms Act, 1959.

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