BEFORE THE FIRST CLASS JUDICIAL MAGISTRATE

AFFIDAVIT
I,……………………………………………………………….. s/w/d of ……………………………………………………… aged ………………
faith/religion ………………………………………………………….. by occupation, Indian residing
at………………………………………………………………………………………………………………………………………………………….....
do hereby solemnly affirm declare as follows:-

1. I have applied for New/Renewal of Clinical Establishment License with on line Application ID No.
…………………………………………….. dated …………………………………….. in Form II along with necessary
documents.
2. That I have applied for NOC Fire/ NOC WBPCB from West Bengal Fire and Safety Department/
West Bengal Pollution Control Board with application no. …………………………………………………………..
dated.............................................with correct supportive information.

However, till date, I have not yet received the NOC from the concerned Department.

I, hereby solemnly affirm and declare that I will submit it immediately (Maximum within 6 months) to
Licensing Authority on receiving from the concerned Department.

And that, I would make myself liable for appropriate legal action including cancellation of License by
Licensing Authority if not complied within stipulated time.

The Statement made herein in above is true to the best of my knowledge and belief.

DEPONENT