FORM A -3

(forindividuals)

Form of application for renewal of arms licence(s) granted in

Form II, III, IV
(See rule 24)
IDENTITY OF THE LICENSEE
1. UIN (16 digit) 132561000684412017

2. Name Himanshu Vaid

3. Parent/Spouse Name Sh. Surinder Kumar Vaid
4. Date of birth in Christian era 20th April, 1983
(a) in figures 20-04-1983
(b) in words Twenty April One Thousand Nine Hundred Eighty Three
5. Present Address H.No. 143/8, Shivaji Colony, Rohtak
(a) Telephone (Office/Residence)
(b) Mobile No. 9812365454
(c) E-mail
(d) Nearest Police Station Thana Shivaji Colony, Rohtak
6. Occupation Doctor
7. Office/Business Address DR. H G SHARMA MEMORIAL DENTAL CLINIC, SHIVAJI
COLONY, OPP. GURUDWARA, ROHTAK

Licence Particulars and Weapon Endorsements

8. Licence Number LN13256A7A9E417 / 771/X/R

9. Date of expiry 05-10-2020
10. Area Validity Haryana
11. Weapons Endorsed Weapon 1 Weapon 2 Weapon 3
(a) Type (Rifle/Shotgun/ Handgun DBBL Gun Revolver
(Rev/Pistol)
(b) Bore/Caliber .12 Bore 032 Bore
(c) Weapon Number 10650.04 001167
12. Ammunition allowed Cartridges
Gun Powder/
Percussion Caps
OTHER PARTICULARS OF THE APPLICANT

13. Whether the applicant since last renewal or issuance of licence has been –

(a) Whether the applicant has been Y N

presently/Previously involved in any criminal FIR No. Date.
case (Whether convicted/acquitted,
Pending/Trail or cancellation/Untraced of FIR). U/S Police Station
Date of sentence
DD/MM/YYYY

(b) ordered to execute a bond under Chapter VIII Y N If yes, details thereof –
of Code of Criminal Procedure, 1973 (2 of
1974) for keeping the peace or for good Date
behavior
DD/MM/YYYY
Period for which
bound
(c) prohibited under the Arms Act, 1959, or any Y N If yes, details thereof –
other law from having the arms or ammunition
Date
DD/MM/YYYY
Period for which
prohibited

14. Whether -
(a) the applicant’s licence since last renewal or Y N If yes, details thereof –
issuance of licence was ever suspended or
Name of the
cancelled/ revoked
licensing authority

Reasons

(b) any other member of the applicant’s family is Y N If yes, details thereof –
in possession of any arms licence, if so,
Name
particulars thereof
Licence No.

Weapons endorsed
1.
2.
3.

(c) the applicant has a safe place to keep the arms Y N If yes, details thereof –
and ammunition

(d) the applicant has undergone prescribed Y N If yes, details thereof –

training as specified under rule 10
(whenever made applicable by the Central
Government)

Declaration:
I hereby declare that the above particulars given in the application are true, complete and correct to the best of my
knowledge and belief. I understand that in the event of any information being found false or incorrect at any stage, I
am liable to be proceeded against and action taken under the relevant provisions of the Arms Act, 1959, the Arms
Rules, 2016, and other central enactments or the law for the time being in force.

Signature /Thumb-impression of applicant

Place Rohtak.
Date 02-0-9-2020
Note:-
The exemptee sports persons shall attach a list of the arms and ammunition held by them in a separate sheet against
columns 11 and 12.
Warning:-

Suppression of any factual information or furnishing of any false or wrong information in the application form in
violation of arms rules will render the applicant liable for punishment under Section 30 of the Arms Act, 1959.
Form S-2

Standard format of undertaking for safe storage of firearms

[See rule 10(4)]

To
The Licensing Authority,
Rohtak.
Undertaking

This is to solely affirm and declare that –

1. I have applied for grant of a renewal of arms licence (bearing number LN13256A7A9E417 / 771/X/R and my
UIN is 132561000684412017)

2. I undertake to practice safe storage of the firearm (in knocked down condition) when I am not carrying the
firearm(s) with me.

3. I undertake to educate the children about the dangers of interacting with arms and ammunition.

4. I have the capacity to store the firearm safely and securely in a safe or steel almirah in order to minimize the
risk that it could be stolen or accessed by someone else.

It is hereby solely affirmed that the declaration made above is true to the best of my knowledge and belief and if at any
subsequent date, if any of the said declarations is found false or incorrect, I shall be liable for the same including
cancellation or revocation of my licence and subject to penal provisions under the Arms Act, 1959.

Place: Rohtak (Signatures of the Applicant/Licensee)

Date: 02-09-2020

Note: Enclose proof of safe storage as mentioned at S.No. 4

Form S-3
Standard format of medical certificate
[See clause (g) of sub-rule (4) of rule 11)] (On
the letter head of the medical practitioner)
This is to certify that I have carefully examined the person whose particulars are furnished below –

1 Name of the person examined Himanshu Vaid

2 Father’s Name/Spouse Name Sh. Surinder Kumar Vaid
3 Residential address H.No. 143/8, Shivaji Colony, Rohtak
4 Age and date of birth 37 years, 20-04-1983
5 Height 5’8”
6 Weight (in Kgs) 92 Kgs
7 Blood pressure (please specify)
8 Deformity, if any
(particularly in upper limbs)
9 Any other observation

On the basis of examination, it is certified that the person examined as mentioned in column 1 above –
1. is in good physical health and is free from any physical deformity;
2. has been found to be of stable mental condition and is not inclined to violence;
3. has been found not dependent on any substance which has an intoxicating or narcotic effect.

Signature of the person examined named in column (1)

Signature of the medical practitioner

Registration Number

SEAL
Form S-4
Standard format of police report
(See rule 14)

DRAFT COVERING LETTER

Office of the DM/Commissioner of Police

Ref. No. Date :

To

The Station House Officer,

Police Station ,

Sub. : Report under section 13(2) of Arms Act, 1959 of the officer in charge of the nearest police station (of
present address of the applicant) on application for grant of arms license or renewal of an arms licence

S.No. Particulars Contents

1 Name of the applicant Mr. Himanshu Vaid

2 Nature of licence applied for (fresh

applications)
3 Licence No. LN13256A7A9E417 / 771/X/R
(renewal application)
4 Address of the applicant H.N. 143/8, Shivaji Colony, Rohtak.

Note: As per provisions of Section 13(2) of Arms Act, 1959, on receipt of an application, the licensing authority shall
call for the report from the officer-in-charge of the nearest police station on the application and such officer shall send
his report within the prescribed time. Accordingly the report be sent in the format attached here within 30 days.

Enclosures:
Copy of application form (original)/renewal form along with enclosures
ANTECENDENT VERIFICATION REPORT

(TO BE FILLED IN BY THE POLICE DEPARTMENT)

1. Name of the applicant

2. Father/Spouse Name

3. Present address

Nearest police station of the present address

4. Whether the applicant has ever been convicted? Yes No

(a)
If so, the offence(s) the sentence and date of sentence

Ordered to execute a bond under Chapter VII of Code of Yes No

Criminal Procedure, 1973 (2 to 1974) for keeping the
peace or for good behavior.
(b)
If so, when and for what period?

Prohibited under the Arms Act, 1959, or any other law

from acquiring, having in his possession or carrying any
arms or ammunition
(c)
If yes, the details thereof

5. Has the applicant any serious enmity or quarrel which is Yes No

likely to lead to a breach of peace? If yes, Give details

6. Has the address and date of birth of the applicant been Yes No
verified? Give details.

7. Has the profession/business of the applicant been verified? Yes No

Give details.

8. Is any complaint registered against applicant in the Police Yes No

Station? If so, give details.

9. Is the applicant involved in any criminal case? If so, give Yes No

details.
10. Has applicant been arrested in any criminal case? If so, Yes No
give details.

11. Is applicant's name enlisted in police station's bad character Yes No

register? If so, give details according to the records of
police station?

12. Is applicant's name appears in any case registered by other Yes No

department of Government of India such as CBI,
Narcotics Control Bureau, DRI, Enforcement Directorate
etc. which finds mention in the Daily Diary Register of the
police station (summons, warrants etc.). If so, give details.

13. Has the applicant registered a complaint in Police Station Yes No

regarding threat to life? If so, give details.

14. Detail of any political or communal organisation of which

the applicant is a member.

Certified that, I have checked the contents of the application form for grant of arms licence submitted by the applicant.

Dated: Signatures
SHO
Police Station

SEAL
UNDERTAKING

I,…………………………..…….S/o Sh……………………………………...
R/o…………………………………………………holder of Arms License No.
…………..………………………………….furnish the following information about
criminal cases registered against me or any proceedings taken against me by the
criminal court.

Details of criminal cases registered against me presently/previously:-

a) FIR No. a) Kalandara/DD No.

b) Under Section b) DD No.
c) Police Station c) Under Section
d) Pending d) Police Station
Investigation
e) Pending trail e) Status
f) Convicted
g) Acquitted

Note:- Please attach the copies of FIR and final decision of the Court.
I, hereby declare that the above information is true and correct to the best of my
knowledge.

Signature:

Date:

Contact No:

Address:
To,

…………………………………………

…………………………………………

…………………………………………

Sir,

I want to get my Arms Licence No.......................renewed.

I submit truthfully that:-

1. Total no of cartridge purchased till date……….

2. Balance cartridge available in my possession………..
3. I had utilized same as under:
i. Date of use ………………………………………..
ii. Place where cartridge were used…..………………………..
……………………………………………………………….
iii. No. of Bullets tried ………………………………………..
iv. Purpose ……………………………………………………..
……………………………………………………………….

I hereby certify that I have not used the above cartridges in any crime and
against law and that the quantity in my possession will not exceed the
maximum limit.

Thanking you

Yours truly,

………………………………………………….. S/O..
…………………………………………..

R/O……..……………………………………..
District………………………………………..