EMBLEM FORM 'E' [See Clause 14(2)(b)] Form of Application to obtain a Certificate of Manufacture, [Import] for special mixture of Fertilisers To The Registering Authority Place: State: (1) Full name and address of the applicant: (2) Does the applicant possess qualifications prescribed by the State Government under Sub-Clause (1) of Clause 14 of the Fertiliser (Control) Order, 1985: (3) Name and address of the person requiring the special mixture of fertilisers: (4) Particulars of certificate(s) of manufacture, [import] already obtained from the same Registering Authority: (5) Situation of the applicant's premises where fertilisers are/will be mixed: (6) Full particulars regarding chemical analysis of the special mixture of fertilisers required to be manufactured and the materials used in making the special mixture: (7) I am enclosing an attested copy of the requisition made by the purchaser of the special mixture of fertilisers: (8) I have deposited the prescribed registration certificate fee: DECLARATION: (a) I/We declare that the information given above is true and correct to the best of my/our knowledge and belief, and no part thereof is false. (b) I/We have carefully read the terms and conditions of the certificate of manufacturers, [importers] given in Form-G appended to the Fertiliser (Control) Order, 1985 and agree to abide by them. (c) I/We declare that the physical/granulated mixture for which certificate of manufacture, [import] is applied for shall be prepared by me/us or by person having such qualifications as may be prescribed by the State Government from time to time or by any other person under my/our direction, supervision and control or under the direction, supervision and control of person having the said qualifications. [(d) I /We declare that the requisite laboratory facility specified by the Controller, under this order is possessed by me/us]. Signature of the Applicant(s) Name and address of applicant in block letters: Date : Place :
