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APPLICATION FORM FOR TEMPORARY PERMIT

I) Type of Application *

II) Details of the applicant

III) Residence/Firm/Company Address

Door No *

Street *

Country *

State *

District *

Mandal *

Village *

Pincode *

PAN Number *

Aadhar Number *
- -

Mobile Number *

Email ID *

IV) Permanent Address (Click here if above Address is same)

Door No *

Street *

Country *

State *

District *

Mandal *

Village *

Pincode *

V) Representative Details

Name

Relation

Mobile Number

Email ID

VI) Work Details

A) Name of the Work Awarded *

Name of the Department *

Work order Number *

Work order Date * (MM/DD/YYYY)

Date of estimation to complete the work * (MM/DD/YYYY)

B) Purpose of Mineral Used For.*

C) Upload Work Order Copy *

VII) Details of the area in respect of which Permit is required

Survey and Range Details *

Survey NoRange

Survey No *

Extent (In Hectares) *

Range *

District *

Mandal *

Village *

Land type*

Plot/DKT No.

VIII) Name of the Mineral applied.*

IX) Mineral requested quantity for permit. *

Quantity *

Unit *

(Note : Please Add atleast one mineral with Quantity and Unit)

X) Geo co-ordinates of the area (Minimum 3 entries) *

i. Latitude N

° - ' - ''

ii. Longitude E

° - ' - ''

XI) Upload Photo of the Applicant*

XII) Upload Signature of the Applicant*

XIII) Upload PAN Card *

XIV) Upload Aadhaar Card *

XV) Upload Affidavit duly notarized for MRCC *

XVI) Upload Affidavit duly notarized for ITCC *

XVII) Upload Applied area sketch *

XVIII) If obtained NOC for Competent Authority *

YesNo

Upload obtained NOC for Competent Authority *

I declare that the above particulars are correct and request that a Temporary Permit may kindly be granted. *

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