DIRECTORATE OF PUBLIC LIBRARIES, TAMIL NADU APPLICATION FORM FOR SUPPLY OF TAMIL / ENGLISH BOOKS YEAR 2013 (Books

ks published during the year of Edition 2010 and 2011) FORM A

Publisher Code No. :
(For Office Use Only)

1.

Name of the Firm Nature of Firm (Publisher / Distributor / Both) (Please write any one option) Address (a) Door No. New (b) Old No. (c) Street (d) Area Name (e) City / Taluk (f) District (g) PIN Code (h) State

2. 3.

: : : : : : : : : : : : : : :

4.

(a) Office Telephone No. (b) Fax No. (c) E-mail

5.

PAN Card No. (a) Bank Account No. (b) Bank Name with Place

6.

Type of Firm
(Proprietor / Partnership / Private Limited / Trust / Society / Public Limited / State Government / Central Government / University Departments / Academic Institution / Others (Please select any one option) (If Others, Please Specify)

7.

1st Contact Person (a) Name (b) Telephone No. Residence (c) Mobile No. (d) E-mail : : : : :

8.

2nd Contact Person (a) Name

(b) Telephone No. Residence (c) Mobile No. (d) E-mail 9. In how many Publish Books Languages you

: : : :

Languages Tamil / English / Malayalam / Kannada / Telugu / Urdu / Hindi 10. Number of Titles that are to be submitted to Directorate of Public Libraries during the Current Year (Only Tamil/ English Books) (a) Amount Remitted in the Name of Directorate of Public Libraries as Registration Fees `
(in the A/c. No. 863124048 at Indian Bank, Thousand Lights Branch, Chennai Amount may be remitted in Indian Bank only)

11.

(b) Details regarding remittance Name of the Bank Branch Date of Remittance

: : :

INDIAN BANK

(Please enclose the Xerox copy of the counterfoil of Bank Remittance Slip with this Application Affix the Seal in the Xerox Copy of the Bank Remittance)

12.

Number of Titles in Tamil (Size wise) (a) Crown Size (b) Demi Size (c) Double Crown Size (d) Double Demi Size (e) Total No. of Books (f)Total No. of Titles submitted in Tamil

: : : : : : : : : PUBLISHERS / BOOK SELLERS SIGNATURE with Office Seal

13. 14.

Total No. of Titles submitted in English Grand Total of Titles Submitted

(Note : No need to specify the size for English Titles)