Date :______________

To
The District Proh. & Excise Officer,
Nizamabad.
// Through Proper Channel //
Sir,
Sub: Proh. & Excise – P&E Station Bodhan - A4 Shops Policy for 2023-25 – Proposals
submitted for issue of licence in favour of Sri
_______________________________________ in name & style M/s.
____________________________________________, A4-Shop at
________________________________________ G.S.No. _______ – Forwarded
herewith – Submitted – Reg.

Ref: 1) G.O.Ms.No. 86, Revenue (Excise-II), Department, dt. 01.08.2023.

2) DPE, T.S., Hyderabad in Cr.No. 3060/2017/CPE/TS/F1, dt. 02.08.2023
3) Gazette Notification No.08, dt. 04.08.2023.
4) DP&EO, Nizamabad provisional License in Cr. No. _____________________,
dt___________.
5) Application of the successful applicant with required documents
dated:_______________.
-ooOoo-

I submit that I have selected through drawl of lots for the A4 Shop notified at
__________________________________________________ with Gazette Sl. No. _______. I have
also remitted an amount of Rs.______________/- towards 1 st instalment of Retail A4
Shop Excise Tax. I am submitting herewith the required documents for issue of licence in FORM-A4
of Telangana Excise Rules, 2012 in the name & style
M/s._______________________________________________________________________ for the
period from 01.12.2023 to 30.11.2025.
1) Check Memo prescribed.
2) (4) Copies of Recent Colour Photographs and clear Xerox copies of Aadhaar card and Pan
Cards and original caste certificate in case if shop allotted to ST/SC/Goud community.
3) Declaration in Form A-1
4) Property declaration in FORM-A2 & FORM-A2(S) on NJS paper worth of Rs.100/- each duly
notarised.
5) Declaration in Form A-3
6) Application in Form-A3 (A) for Permit Room with court fee stamp of Rs.100/-.
7) Application in Form-A4 (A) for Permit Room with court fee stamp of Rs.100/-.
8) (1) Bank Guarantee worth 25% of annual RSET valid for (25) months in FORM-A5
9) Counterpart Agreement in FORM-A6 on NJS paper worth of Rs.100/-.
10) Affidavit for Self declaration under Rule 8 of Shop Rules on NJS paper worth of requisite value
duly notarised.
11) Affidavit for installation of required machinery (HPFS) in A4 Shop on NJS paper worth of
requisite value duly notarised.
12) Rental Agreement for A4-Shop and Permit Room separately and No objection letter from
owner of the premises.
13) (3) Nowkarnama proposals along with clear Xerox of I.D. proof and requisite fee remitted
original Challan’s.
14) (4) Sets Blue Print Maps for A4-Shop and Permit Room separately.

Yours faithfully,
Encl:- as above
( )
M/s._______________________________
__________________________________
G. SL. No. __________.
Copy submitted to the Proh. & Excise Inspector, P&E Station, Bodhan with a request to forward
the above documents to the DP&EO, Nizamabad with recommendation for issue of licence in
FORM-A4.