F O R M - A ( See Clause 8 ) FORM OF APPLICATION TO OBTAIN DEALER'S (WHOLESALE OR RETAIL OR INDUSTRIAL) CERTIFICATE OF REGISTRATION To The Registering Authority / Controller(lf the application is for industrial dealer's certificate of registration) Place . . . . . . Stateof .... .. 1. Full name and address of the applicant: (a) Name of the concern and postaladdress :.............. (b) Place of business (Pleasegiveexactaddress) :.............. i)Forsale :.............. ii)Forstorage :.............. 2. Is it a proprietory/partnership/: . . . . . . . . . . . . . . limited company/Hindu Undivided Family concern ? Give the name(s) and address(es) of proprietor/ partners/manager/karta 3. In what capacity is this application filed. (i) Proprietor (ii) Partner (iii) Manager (iv) Karta 4. Whether the application is for wholesale or retail or industrial dealership ? : 5. Have you ever had a fertiliser dealership registration certificate in the past ? If so, give the following details : (i) Registration number (ii) Place for which granted (iii) Whether wholesale or retail or industrial dealership (iv) Date of grant of registration Certificate (v) Whether the registration certificate is still valid ? (vi) If not, when expired ? (vii) Reasons for non-renewal (viii)If suspended/cancelled and if so, when (ix) Quantity of fertilisers handled during last year (x) Names of products handled (xi) Name of source of supply of fertilisers 6. Was the applicant ever convicted under the Essential Commodities Act,1955 or any Order issued thereunder including the Fertiliser (Control) Order, 1957 during the last three years preceding the date of application ? lf so give details. Contd... -(2)- Give the details of the fertilisers to be handled Sl.No. Name of Fertiliser Source of supply 8. Please attach certificate(s) of source from the supplier(s) indicated under column 3 of Sl.No.7. 9. I have deposited the registration fee of Rs. . . . . videChallanNo........... dated........in treasury/Bank or enclose the Demand Draft No. . . . . . . . . . dated.....forRs. .......drawnon........ bank, in favour of payable at . . . . . . . . . . . towards registration fee.(Please strike-out whichever is not applicable). 10. Declaration : (a) I/we declare that the information given above is true 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 Registration given in form 'B' appended to the Fertiliser (Control) Order, 1985 and agree to abide by them. (c) I/we declare that I/we do not possess a certificate of registration for industrial dealer and that I/we shall not sell fertilizers for industrial use.(Applicable in case a person intends to obtain a wholesale dealer or retail dealer certificate of registration, excepting a State Government, a manufacturer or a pool handling agency). (d) I/we declare that I/we do not possess a certificate of registration for wholesale dealer or retail dealer and that I/we shall not sell fertilizers for agricultural use. (Applicable in case a person intends to obtain a industrial dealer certificate of registration, excepting a State Government, a manufacturer or a pool handling agency). Signature of the Applicant(s) Date : Place :
