FORM A (See Clause 8) FORM OF APPLICATION TO OBTAIN DEALERS (WHOLESALE OR RETAIL) CERTIFICATE OF REGISTRATION. To The Registering Authority, Place State of 1. Full name and address of the applicant:- a. Name of the concern and Postal address : b. Place of business (Please give exact address): i. For sale: ii. For storage: 2. Is it a proprietary/Partnership/limited company/Hindu Undivided Family concern Give the Name(s) and Address(es) of Proprietor/Partner/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 dealership? 5. Have you ever had a fertilizer 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 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. Quality of fertilizers, handled during the year x. Names of products handled: xi. Name of source of supply of fertilizers 6. Was the applicant ever convicted under the Essential Commodities Act 1955. Or any order issued there under including the Fertilizer (Control) Order 2957, during the last three years proceeding the date of application. If so give details. 7. Give the details of the fertilizers to be handled: Sl.No Name of Fertilizer Source of supply 8. Please attach certificiate(s) of source from the supplier(s) indicate under column (3) of serial No.7. 1. I have deposited the Registration fee of RS. Vide Challan No. Dated: in Treasury/Bank 9. Declaration: a. I/We declare that the information given above is true to the best of my/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 Fertilizer (Control) Order, 1985, and agree to abide by them. Signature of the Applicant(s) Place: Date: Notes: 1. Where the business of selling fertilizers is intended to be carried on at more than one place, a separate application should be made for registration in respect of each such place. 2. Where a person intends to carry as the business of selling fertilizers both in retail and wholesale, separate applications for retail and wholesale business should be made. 3. Where a person represents or intends to represent more than one State Government, Commodity Board, Manufacturer or Wholesale dealer, separate Certificate or source from each such source should be enclosed. FOR USE IN OFFICE OF REGISTERING AUTHORITY Date of receipt: Name and designation of Officer receiving the application.
