(Specimen of affidavit to be submitted by applicant on a non-judicial stamp paper worth
Rs. 10/- duly attested by a Notary Public.)
I,_____________________________Son/husband of Shri.____________________________
resident of _________________________________ applying for Video Game Parlour License
located at ________________________________ do hereby solemnly undertake and declare as
1. That the location and functioning of the proposed Video Game Parlour is free from all legal
encumbrances and also does not in any manner violate the condones of MPD-2021
2. That I have installed ___________No/s. of machines at the above said Video Game Parlour.
3. That I shall charge a sum of Rs.______ per game for _____ minutes duration.
4. That I shall prevent over-crowding at the premises and shall not allow more that____ person
including children per machine, inside the premises.
5. That I shall observe the prescribed timing for opening and closing the said Video Game
Parlour and shall not open it beyond 10.00 PM.
6. That I shall not allow any child in school uniform below the age of 15 years to play the game
in the parlour.
7. That I shall not allow the said premises to be used for gambling or betting purposes in any
manner. The Licensing Authority is empowered to take action if any customer is found
indulging in betting etc as per law.
8. That I shall not allow customers to park their vehicles so as to cause any
obstruction/inconvenience to the general public at the site.
9. That the music shall be played at the premises in conformity with the directions given under
regulation and shall under no circumstances be audible beyond 15 feet.
10. That I shall comply with all the provisions of the Regulations, Building Bye-Laws and other
laws applicable at the Premises.
11. That I shall adopt all safety norms such as Fire, Fighting system and Electrical installations
required as per rules in good working conditions at the said premises.
12. That I shall not allow the patrons to smoke inside the said premises.
13. That I shall provide sufficient number of spittoons at the suitable place and keep my Video
Game Parlour in neat and clean as well as in good hygienic condition.
14. That I shall display the license at a conspicuous place in the Video Game Parlour.
15. That I shall provide sufficient emergency lights in the premises at suitable places.
16. That I shall comply with the directions of the local police communicated from time to time.
17. That I shall extend all facilities to inspect the premises on their visits and shall abide by all
terms and conditions in removing the defects/deficiencies pointed out by the statutory
authorities from time to time.
I__________________________________ do hereby solemnly affirm and undertake that
all the concents of above affidavit are true and correct to the best of my knowledge.
(Signature and seal of Notary Public.)