APPLICATION FOR APPOINTMENT AS AUTHORISED RETAIL DISTRIBUTOR (See Clause 45 (2) of the Kerala Rationing Order, 1966) 1. Applicant's Name and Address 2. Date of birth and completed years of age 3. Educational qualification, if any (Certified copy in proof to be produced) 4. If no educational qualification is possessed, is the applicant literate. (Certificate of literacy from any Government Officer, not below the rank of a Class II Officer or Panchayat President to be produced) 5. Business or occupation of the applicant 6. 1) Whether the applicant is solvent and if so to what extent (solvency certificate obtained from the Tahsildar to be produced in original, Valuation Certificate will not be accepted) 2) Whether the applicant is a Co-operative Society, a solvency Certificate from the Deputy Registrar of Co-operative Societies and a Certificate from an Officer of the Co-operative Department showing the profit or loss earned or incurred by the society during the latest year for which audited balance is available are to be produced in original 7) Whether the applicant possess experience as Licensee of an authorised retail dealer or authorised wholesale dealer or salesman in an authorised retail dealer or authorised wholesale dealer and if so give details or 1) Name, number and location of authorised retail dealer : 2) Nature of experience : 3) Length of experience and exact period (Certificate if any obtained to be produced in original) 8 Whether the applicant had applied for appointment as an authorised retail dealer or authorised wholesale dealer during the past 3 years and if so, give details of : 1) Name, number and location of the authorised retail dealer/authorised wholesale dealer for which application was made 2) Date or approximate period when the application was made 3) Result of application 9 Details of place where the retail shop will be established (Name of Corporation/ Municipality/Panchayat ward number and building number) (consent letter of the owner of the building to let it on hire to be produced in the case of building to be taken on lease) 10 Whether the applicant has experience in the sale of foodgrains and if so give details 11 Whether the applicant passesses a licence (wholesale/retail under the Kerala Rationing Order, 1966, Kerala foodgrains Dealer's Licensing Order 1967 Kerala Kerosene Control Order, 1968, Kerala Pulses Dealer's Licensing Order, 1972 and the Rice Milling Industry Regulation Act, 1958), and if so licence number and date and location of the place of business. 12. Whether the applicant is having business or partnership in the purchase and sale of foodgrains in open market and if so, give details 13 Whether relatives (father, mother wife sons and daughters are running authorised retail depot or authorised wholesale depot and if so specify relationsip, name, number and location of authorised retail depot/authorised wholesale depot 14 Whether he intends to run the shop as a full time business DECLARATION 1) I/We have familiarised myself / ourselves with the conditions regulating the appointment and agree to abide by them if selected. 2) I/We declare that I /We have not been convicted by a court of law in respect of contravention of any order made section 3 of essential commodities act, 1955 (Central Act 10 of 1955) relating to foodstuffs including Edible Oil Seeds Oils or any order issued under Rule 114 of the Defence of India Rules 1971 relating to control and distribution of foodstuffs. 3) I/We also certify that the above information is true to the best of my/our knowledge and I/We agree that furnishing of false information will render my/our application liable to be rejected. Place : Signature of the Applicant Date : Note:- 1) Item No.2,3,4.12 and 14 are not applicable to co-operative societies. 2) Incomplete applications are liable to be rejected. FOR OFFICE USE ONLY 1 Date of receipt of application - 2 Report of the Officer conducting enquiry - 3 Order of the District Supply Officer - 4 Date of issue of order of appointment - 5 Date of execution of agreement - Signature of District Supply Officer Trivandrum Commissioner of Civil Supplies
