FORM-AI 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 3. Place of business (Please give full address) (i) For Sale (ii) For Storage 4. Whether the application is for- Manufacturer Importer Pool Handling Agency Wholesale Dealer Retail Dealer (Tick mark whichever is applicable) 5. Details of fertilizer and their source in Form 'O' Name of fertilizer Whether certificate of source in Form 'O' is attached (i) Yes No (ii) Yes No (iii) Yes No (Please tick mark whichever is applicable) 1. I have deposited the registration fee of Rs._________________________________________ vide Challan no._____________________Dated_______________________________________ in bank/ Treasury_____________________________________________________or enclose Demand Draft No._______________________________________Dated_____________for Rs. ______________________________________ drawn on ___________________ in favour of ____________________________________payable at _________________________________ towards registration fees. Whether the intimation is for an authorization letter or a renewal thereof . (Note : In case the intimation is for renewal of authorization letter, the acknowledgement in Form A2 should be submitted for necessary endorsement thereon). 2. Any other relevant information. I have read the terms and conditions of eligibility for submission 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
