FOOD & CIVIL SUPPLIES & CONSUMER AFFAIRS DEPARTMENT GOVERNMENT OF SIKKIM (SIKKIM) SL. No............. .. Br. No: ....... Date: ..................... Amount ................... . APPLICATION FORM FOR REGISTRATION OF FAIR PRICE SHOP i) Name of the Applicant: ......................................................... ....... ii) a. Father's/Husband's Name: ............................................................................. b. S.C.C./I.D. Certificate, if any, with Xerox copy: ............................................... iii) Address of the Applicant: ......................... ....................... ... .......... . .. .................................................................................................................................... Street/Lane : ................................................................... .. ................................................................... .............. P.O. : ..................................................... ................. Ward ...................................................................Gram Panchayat Unit .... .. .......................................................................... Constituency ................................................................................................... iv) Firm name, if any, with registration No ................................................. ... .. ...................................................................................... v) Address where the business is established/run : Street/Lane .................................................................................................................................. ........................................... .............. P.O ...................................................................................................... .... Ward ....................................................................Gram Panchayat Unit ... .. ....................... ........................... Constituency ................................................................................................................. vi) Category of the firm and status of the applicant ................. ........ .. ............................................................................................. ....... 1. Proprietorship (1) Owner 2. Partnership (2) Partner 3. Company (registered under (3) Managing Director/Manager Companies Act) 4. Co-operative Society (registered (4) Secretary under Co-operative Society Act) (5) Authorised Agent (Enclose Xerox copies of registration, if any) vii) Trade License No. ........................................dated............................................. issued by Urban & Housing Department, Government of Sikkim (Xerox copy to be enclosed) viii) Application submitted for approval of: (1) Fair Price Shop (2) Allotment of quota of wheat & wheat products (3) Allotment of quota of S. K. Oil (4) Allotment of quota of salt (5) Allotment of quota of Rice/Sugar (6) Allotment of quota of Palmoline Oil ix) The business establishment is housed in and has run for : (1) Own Building/House (1) New establishment (2) Rented Building/premises (2) ..................years (3) Govt. allotted premises (4) Institutional premises x) Whether Godown/Storage facilities are available in the same building or are separate ........................................................................................................................................................ ......................................... ...................... xi) In the case of application submitted for Fair Price Shop, how many ration cards are likely to be catered to by the applicant's proposed shop? ............. . ........................................................................................................................................ xii) Whether the applicant is financially sound to lift the allotted items under PDS regularly YES/NO Mere submission to the filled in form neither confers any right to the applicant nor does it guarantee the approval of the Fair Price Shop/Nominee in favour of the applicant. The Department of Food & Civil Supplies and Consumer Affairs reserves the right to accept or reject the application subject to the merit of the case. The details furnished above are true. Any false representation will make me liable foe cancellation of the license and the penal action as per law. I shall abide by the terms and conditions of the Food & Civil Supplies and Consumer Affairs Department for the approval of the Fair Price Shop/allotment of quota and their regulations issued from time to time. (Signature of the Applicant)
