FORM `A1’
MEMORANDUM OF INTIMATION
[See Clause 8 (2)]
1. Details of the application :
(a) Name of the applicant_____________________________________________
(b) Name of the concern______________________________________________
(c) Postal address with telephone number________________________________
(d) Mobile number__________________________________________________
2. Place of business (Please given full address)
(i) For Sale
(ii) For Storage
3. Whether the application is for –
Manufacturer [ ] Importer [ ] Pool handling Agency [ ]
Wholesale Dealer [ ] Retail Dealer [ ]
[Tick mark whichever is applicable]
4. Details of fertilizer and their source in form ‘O’
Name of fertilizer whether certificate if source in Form ‘O’ is attached
(i) Yes No
(ii) Yes No
(iii) Yes No
[Tick mark whichever is applicable, Attach a separate sheet if the number exceed three]
5. I have deposited the registration fee of Rs.______________ vide Challan No.
_______________________ Dated ____________________ in the Bank/treasury
Or enclose Demand Draft No. _____________________________________________
Dated_______________________For Rs._____________________________ drawn on
____________________________in favor of __________________________________
Payable at __________________________ towards registration fees.
6. 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.)
7. Any other relevant information.
I have read the terms and condition of eligibility for submission of memorandum if intimation
and undertake that the same will be complied by ne and un token of the same. I have signed the
same is enclosed herewith.
Date:
P lace: Signature of applicants
Terms and condition of authorization:
(1) I shall comply with the provisions of the Fertilizer (Control) Order, 1985 and the
notification issued there under for the time being in force.
(2) I shall form time to time report to the Notified Authority and inform about change in the
premises of sale depot and godowns attached to sale depot.
(3) I shall also submit in time all the returns as may be prescribed by the State Government.
(4) I shall not sale fertilizer for industrial use.
(5) I shall file a separate memorandum of Intimation for, where the storage point is located
outside the area jurisdiction of the Notified Authority where the sale depot is located.
(6) I shall file a separate memorandum of Intimation for each place when the business of
selling fertilizers is intended to be carried on at more than one place.
(7) I shall file a separate memorandum of Intimation if I carry on the business of fertilizer
both as retail and wholesale dealer.
(8) I confirm that my previous certificate if Registration or Authorization is not under
Suspension or cancellation or debarred from selling of fertilizers.
DECLARATION
I/we declare that the information given above is true to the best of my/ our knowledge and belief
and no part thereof is false or no material information has been concealed.
Signature of the Applicant (s)
Date:
Place
