The Orissa Entry Tax - Forms
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FORM E 17 A

[See rule 4 (2) (a)]

DETAILS OF ADDITIONAL PLACES OF BUSINESS/BRANCHES/GODOWNS/

WAREHOUSES IN ORISSA

01.	Name and style of the business:
02.	Address:
03.	Name of the applicant:
04.	Additional place of business/ Branch/Godown or Warehouse
	(Score out whichever is not applicable)
	ADDRESS___________________________________________________
		___________________________________________________
		___________________________________________________
	Pin Code ______________Telephone___________Fax_______________
	Signature		Date__________________
	05. Additional place of business/ Branch/Godown or Warehouse
	(Score out whichever is not applicable)
	ADDRESS___________________________________________________
		___________________________________________________
		___________________________________________________
	Pin Code ______________Telephone___________Fax_______________
	Signature		Date__________________
	06. Additional place of business/ Branch/Godown or Warehouse
	(Score out whichever is not applicable)
	ADDRESS___________________________________________________
		___________________________________________________
		___________________________________________________
	Pin Code ______________Telephone___________Fax_______________
	Signature		Date__________________

VERIFICATION

I --------------------------------------------------------son/daughter/wife of ----------------------------------------- status --------------------------------of the aforesaid business do hereby solemnly affirm that the particulars given in this form are true and correct to the best of my knowledge and belief.

	Signature
Seal
Date:___________________