FORM 'O' [See Clause 8 and 11] CERTIFICATE OF SOURCE FOR CARRYING ON THE BUSINESS OF SELLING FERTILISERS IN WHOLESALE/RETAIL/FOR INDUSTRIAL USE No. ........................... Date of issue ............................. 1. Particulars of the concern issuing the certificate of source (a) Name and full address (b) Status : (i) State Government (ii) Manufacturer (iii) Pool handling agency (iv) Wholesale dealer (v) Importer (c) If manufacturer of mixture of fertilisers, the details of certificate of manufacture of mixture of fertilisers possessed : (i) Number (ii) Date of Issue (iii) Date of expiry (iv) Grades of mixturers of fertilisers allowed to be manufactured (v) Authority by whom issued (d) Details of certificate of registration : (i) Number (ii) Date of issue (iii) Date of expiry (iv) Authority by whom issued 2. Particulars of the person to whom the certificate of source is being issued (a) Name and full address (b) Status (i) Wholesale dealer (ii) Retail dealer (iii) Industrial dealer (c) If holds a valid certificate of registration, the details thereof : (i) Number (ii) Date of issue (iii) Date of expiry (iv) Autority by whom issued (d) Purpose of obtaining the certificate of source : (i) For obtaining a fresh certificate of registration (ii) For renewal of the certificate of registration. 3. Details of fertiliser(s) to be supplied : S. No. Name of fertilisers Trade mark/Brand name (1) 1. 2. 3. 4. (2) (3) Declaration Declared that the fertilisers mentioned above will be supplied conforming to the standards laid down under the Fertiliser (Control) Order, 1985 and, as the case may be, grades/formulations (of mixtures of fertilisers) notified by the Central/State Government and packed and marked in container as provided under clause 21 of the Fertiliser (Control) Order, 1985 Signature with stamp of the Authorised Officer
