Form A1 MEMORANDUM OF INTIMATION [ See Clause 8(2) ] 1. Details of the Notified Authority to whom application is submitted. Designation of Notified Authority _________________ Place ________________________________________ State of _______________________________________ 2. Details of the applicant : a. Name of the Applicant : b. Name of the Concern : c. Postal address with telephone number : 3. Place of business (Please give full address ) (i) For Sale : (ii) For Storage 4. Whether the Applicant is for :- Manufacturer Retail Dealer Importer Pool Handling Agency Wholesale Dealer [tick mark whichever is applicable ] 5. Details of fertiliser and their source in Form "O" * Name of Fertiliser Whether certificate of source in form "O" is attached (i) Yes No (ii) Yes No (iii) Yes No [ Please tick mark whichever is applicable ] 6. I have deposited the registration fee of Rs. __________________________ vide Challan No.____________________ Dated ___________________ in the Bank/Treasury _______________________________________ or enclose Demand Draft No. _______________________________ dated ______________________ for Rs.______________________ drawn on _____________________________________ in favour of__________________________________ payable at ___________________ towards registration fees. 7. Whether the intimation is for an authorisation letter or a renewal thereof. (Note : In case the intimation is for renewal of authorisation letter, the acknowledgement in Form A2 should be submitted for necessary endorsement thereon.) 8. Any other relevant information. I have read the terms and conditions of eligibility for submissions of Memorandum of Intimation and undertake that the same will be complied by me and in token of the same, I have signed the same and is enclosed herewith. Date : Place : Signature of the Applicant * Attachment a separate sheet if the number exceeds three. TERMS AND CONDITION OF AUTHORISATION 1. I shall comply with the provisions of the Fertilizer(Control) Order, 1985 and the notifications issued thereunder for the time being in force. 2. I shall from time to time report to the Notified Authority and inform about change in the premises of sale depot and godowns attached to sale depot. 3. I shall also submit in time all the returns as may be prescribed by the State Government. 4. I shall, not sell fertilisers for industrial use. 5. I shall file a separate Memorandum of Intimation for, where the storage point is located outside the area jurisdiction of the Notified Authority where the sale depot is located. 6. I shall file a separate MOI for each place when the business of selling fertilisers is intended to be carried on at more than one place. 7. I shall file separate MOI if I carry on the business of fertilisers both as retail and wholesale " dealer. 8. I confirm that my previous certificate of Registration or Authorisation is not under Suspension or Cancellation or debarred from selling of fertilisers. DECLARATION 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 or no material information has been concealed. Signature of the Applicant (s) Date : Place :
