EMBLEM FORM 'O' [See Clauses 8 and 11] No. ....................................... Date of Issue ............................... Certificate of source for carrying on the business of selling fertilisers in wholesale /retail/ for industrial use. 1. Particulars of the concern issuing the certificate of source : (a) Name and full address : (b) Status : (i) State Government (ii) Manufacturer, [Importer] (iii) Pool handling agency (iv) Wholesale dealer. (c) If manufacturer, [importer] of mixture of fertilisers, the details of certificate of manufacture, [import] of mixture of fertilisers possessed: (i) Number (ii) Date of Issue (iii) Date of expiry (iv) Grades of mixtures 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) Authority 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 the Fertiliser(s) to be supplied Sl. No. Name of Fertilisers Trade mark/Brand name 12 3 1. 2. 3. 4. 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
