FERTILISER (CONTROL) ORDER, 1985 EMBLEM FORM A (See CI.8) Form of Application to Obtain Dealer's (Wholesale or Retail) [or Industrial] Certificate of Registration To The Registering Authority2 /Controller (if the application for Industrial dealer's certificate of Registration)/ 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. If it is a proprietary/partnership/limited company/Hindu undivided family concern? Give the name(s) and address(es) of proprietor/Partners/manager/Karta: 3. In which capacity is this application filed. i. Proprietor. ii. Partner. iii. Manager. iv. Karta. 4. Whether the application is for wholesale or retail (or industrial) 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 2 (or Industrial 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. Quantity of fertilizers, handled during last year x. Names of products handled xi. Names of sources of supply of fertilizers. 6. Was the applicant ever convicted under the Essential Commodities Act, 1955, or any Order issued there under including the Fertiliser (Control) Order, 1957, during the last three years preceding the date of application? If so, give details. 7. Give the details of the fertilizers to be handled: ________________________________________________________________________________________________ Sr. No. Name of fertilizer Source of Supply 8. Please attach certificate (s) of source from the supplier(s) indicated under Col. 3 of Sr. No.7 9. I have deposited the registration fee of Rs.____________vide Challan No.________dated in treasury/bank __________________[or I enclose the Demand Draft No.___________________dated for Rs. _____________drawn on Bank, in favour of _________________ payable at____________towards registration fee. (Please strike out whichever is not applicable). 10. Declaration:-
