Application No: 156387005539784

Proprietorship
FORM 'A1'
MEMORANDUM OF INTIMATION
[See Clause 8(2)]
1. Details of application:

(a) Name of the applicant BANKIM CHANDRA DUTTA , Proprietor

(b) Name of the concern BANKIM CHANDRA DUTTA

(c) Postal address with telephone number kandi, P.O - KANDI, P.S - KANDI, PIN - 742137

(d) Mobile number 9474646653

(e) Existing Licensing Number 31/RR/KAN/2019-22

(f) Date Of Issue 18/07/2019

(g) Valid Upto 20/03/2022

(h) mFMS id 456310

2. Place of business (Please give full address):

(i) For Sale

Village : 84
Dag no : 15
Khatian no : 771
Road : DOHALIA BAIPAS
Mouza : Dohalia
Block : KANDI SADAR
Subdivision : Kandi
District : Murshidabad
State : West Bengal
(ii) For Storage
Details attached on Annexure - A
3. Wherther the application is for :
LOA for Retail Dealer for Subdivision
4. Details of fertilizer and their source in Form 'O' : Details attached on Annexure - B

5. Payment Not Applicable for Digitization of old license

6. Any other relevant information

Place:______________Dated : ___/____/_____ Signature of Applicant

 Application No: 156387005539784

I have read the terms and conditions of eligibility of 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 is enclosed herewith.

Terms and Conditions of authorization:

1. I shall comply with the provisions of the Fertilizer (Control) Order, 1985 and the notification issued
thereunder for the time being in force.
2. I shall from time to time report to the Notified Authority and inform about change in the premises of sale
depot and go downs 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 sell fertilizers 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 separate Memorandum of Intimation if I carry on the business of fertilizers both as retail and
wholesale dealer.
8. I confirm that my previous certificate of 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.

Place:______________Dated : ___/____/_____ Signature of Applicant

 Application No: 156387005539784

Annexure - A (Store location details)

Storage Details : --------------------------------------------------
Name : BANKIM CHANDRA DUTTA
Village : 84
Dag no : 15
Khatian no : 771
Road : DOHALIA BAIPAL
Mouza : Dohalia
Block : KANDI SADAR
Subdivision : Kandi
District : Murshidabad
State : West Bengal
Annexure - B ('O' Form details)
(1) 'O' Form Details : -------------------------------------------
Company Name: GOLAM KIBRIA
Form number: 022/G.H./2019-2020
Fertilisers: Urea (46% N) (IFFCO, TATA, RCF,
GOMOR), N.P.K. (10-26-26) (IFFCO,
GOMOR, RCF, NABARATNA), Zinc
Sulphate Monohydrate (Granular) (TATA,
PARAS)
Valid Upto: 20/03/2022
(2) 'O' Form Details : -------------------------------------------
Company Name: JOYDEV PAUL
Form number: 093/JDP/2018-19
Fertilisers: Urea (46% N) (IFFCO, GROMOR),
Neem Coated Urea (IFFOC ), Neem
Coated Urea (Granular) (GOOMOR),
N.P.K. (10-26-26) (IFFCO, PARA,
GOOMOR)
Valid Upto: 10/03/2022
(3) 'O' Form Details : -------------------------------------------
Company Name: CHAND GOPAL PAL
Form number: 090/CSP/2018-2019
Fertilisers: Urea (46% N) (NSCL ), Neem Coated
Urea (NSCL), Potassium Sulphate
(RAJA), Zincated NPK Complex
(10:26:26) (IFFCO NABARATNA,
PARAS ), N.P.K. 20:20:20 (PARAS, PPL
IFFCO)
Valid Upto: 10/03/2022

Place:______________Dated : ___/____/_____ Signature of Applicant

 Application No: 156387005539784

I shall show the all relevant/uploaded documents in original & submit the photocopy of the same
along with this Application Form (Form A1) at the time of inspection.

Place:______________Dated : ___/____/_____ Signature of Applicant