The Orissa Entry Tax - Forms
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FORM E17B

[See rule 4 (2) (b)]

DECLARATION OF PROPRIETOR/ PARTNERS/DIRECTORS/AUTHORISED PERSONS OF THE BUSINESS

Note :- Proprietor , Each Partner / Director , Authorised Officer/ person shall fill up the particulars below.

(Separate forms duly filled in and signed shall be furnished in respect of each Partner / Director / Person )

01.	Full Name :
	(in block letter)
02.	Name of Father / Husband :
03.	Date of Birth :
04.	Educational Qualification :
05.	Extent of interest in the business :
	(i) Official designation
	(ii) Date of joining in the present capacity.
06.	Present Address :
07.	Permanent Address :
08.	PAN (Income Tax)
09.	Other business interests in the state
	( Specify details of such interests including relations in business)
	Other business interests out side the state( Specify details of such interests including relations in business)
10.	Proof of Identity :
	(Enclose copy of voter's Identity Card/PAN)
11.	Reference of two registered dealers with name, address and telephone number.
	( Not applicable to Companies incorporated under the Companies Act, 1956)
	Specimen Signature	1. ____________________________
		2. ____________________________
		3. ____________________________

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.

Full Signature
Status with relation to the business.	Date : _______________
Seal	Place : ______________