1.  Full name and address of applicant : .............................................

2.  * Kind of plant: ..............................................................................

3. * Designation:  ...............................................................................

4.  Name and address of business:  ...................................................

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5.  I hereby apply, in respect of the above-mentioned, for a copy of the document in connection with:

       ....................................................................................................

6.   Purpose for which copy is required: ..............................................

        ....................................................................................................

7.  Signed at (place) ..................................this ............... day of (month) ..........................19  ........

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Signature of applicant