ANNEXURE-XI Andhra Pradesh Medical & Aromatic Plants Board Hyderabad. APPLICATION FOR GRANT OF CERTIFICATION OF REGISTRATION / RENEWAL AS MEDICINAL PLANTS COLLECTOR (S) / FRAMER (S) / TRADER (S) 1. a) Name of the Applicant (s) / contact person (in block letters) : b) Status ( individual / firm / company / society / association / contractor / Govt. undertaking ) c) Date of establishment / engagement in the field of medicinal plants ( trader enclose profile, if any ) d) Fresh or renewal, if renewal, give previous year's certificate. e) Amount and details of fee remitted. f) If already registered, furnish details with the name of the State and agency GO or NGO (attach copy of registration) 2. a) Address in full of the place (s) of storage / shop / processing plant / unit (s) etc., if any b) Telephone, Fax and email number(s) 3. Whether A) Collector B) Farmer C) Trader (Mention specifically) ____________________ A. COLLECTOR (s) 4. Item of medicinal plants / parts / products collected (furnish details including aprox. quantity collected in following table): S.No. Name of Herb(s) Botanical name Area of collection with Dist. / Forest Div. Approx. Quantity (kg.) 1. 2. 3. 5. Are you an authorized collector of medicinal plants? (with permission of Govt. or other authorized body) 6. Year during which the application was in possession of Board's certificate of registration (for renewal only) 7. Whether collected product supplied under some brand name(s) trade mark (s) 8. Medicinal plants material collected and supplied i.e. raw / semi processed or processed during last 03 years. S.No. Year Name of the species collected Area from where collected Appox Quantity Two Whom Supplied (Kg.) 1. 2. 3. B. FARMER(s) 9. Details of Land: a) Location (given name of state / district / tehsil / mandal / village ) etc. b) Status & title of land , whether on lease or free hold (attach a copy of ownership/land registration) c) Area (in acre) 10. Medical plants cultivated: furnish list with details: S.No. Common name of the plant Botanical Name with plant / product Area under cultivation(acre) 1. 2. 3. 4. C. TRADERS: I. Sources of purchase / collection : from wild or cultivated: II. Sate areas where items supplied in last three years S.No Year Name of species State Approx. quantity (qtl.) FOB Value (Rs.) DECLARATION I/We, declare that the information given above is true to the best of my knowledge and belief and that I/we shall abide by the Board Rules and conditions laid down in the certificate and any instruction(s) given by the board from time to time regarding the conducting of business. Place: Date: Signature of the Applicant (s) (With seal)
