[See rule 6 (n)] 1. Name of the applicant 2. Present address of the applicant 3. Particulars of the licence to be surrendered (a) Number (b) Date (c) Name of the holder (d) Period with dates of validity. 4. Reason for surrendering the licence. I/We hereby declare my/our intention to’ surrendering the licence aforesaid, of which I/we/am/are holder (s) and am/are aware that on the acceptance of this surrender, I/we will not be entitled to any compensation by way of refund of licence fee or in any other form. I/We hereby attach a declaration in Form V of the stock of- antiquities held by me/us on the date of this declaration and hereby undertake to submit another declaration of Form VI immediately six months after the date of acceptance of this surrender. Place Signature and name of the applicant Date No. of licence Seal of the firm.]
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