ड लर शप आव दनप DEALERSHIP APPLICATION (आव दक इस न भर - क वल क य लय य ग क लए) ( Not to be filled by the Applicant OFFICE USE ONLY ) 1.
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1 FORMAT/MKT/NMP/017-B Form No.: प व ल फ ट ल इज़र क प र शन ल मट ड Brahmaputra Valley Fertilizer Corporation Limited ( A Government of India Undertaking ) Marketing Division, Corporate Office Namrup P.O. Parbatpur PIN Distt. Dibrugarh (Assam) marketing@bvfcl.co.in, marketing_it@bvfcl.co.in स म य वग क लए आव दनप श क Application form Fee for General category Rs भ गत न र ड.ड न.... दन क... ब क... Paid by :- DD No.. Date. Bank नगद भ गत न र रस द... दन क... Paid by Cash:- M.R. No.. Date. अन स चत ज त / अन स चत जनज त क लए आव दनप श क... नल (क पय, ज त क म ण-प स गन कर ) Application-form Fee for SC / ST category Nil ( On production of copy of Caste Certificate ) ज र कत अ धक र ड लर शप आव दनप DEALERSHIP APPLICATION (आव दक इस न भर - क वल क य लय य ग क लए) ( Not to be filled by the Applicant OFFICE USE ONLY ) 1. आव दक स थ क न म पदन म Issuing officer Designation Name of the Applicant firm वग Category.. 3. र य State.. 4. ज़ल District. 5. त स ल / त ल क Tehsil / Taluka.. 6. ल क / म ड Block / Mandi.. 7. म ड / थ न Mandi / Place applied.. 8. अन म नत व ष क आ ट क(म.टन) Estimated Annual Off Take(MTs)... (Please read carefully and fill up all the columns. Incomplete applications are liable to be rejected.) 1.
2 Attested Coloured Photographs to be pasted with their Names & status of Dealership applicant(s) आव दनकत स थ क न म... Name of the Firm : M/s. A. Proprietor / CMD / MD / Managing Partner of the applicant Firm आव दनकत स थ क एकम ऽ व म क न म B. Partners / Directors of the Applicant Firm आव दनकत स थ क भ गद र / नद शकगण क न म 2
3 1 2 आव दनकत स थ क न म Name of the Applicant Firm पऽ च र क लय पर पत Postal Address 3 पन क ड न बर PIN code No. ट लफ न एस.ट.ड क ड न बर स हत 4 Tele. No. with STD code No. 5 म ब इल न बर Mobile No. 6 फ स न बर Fax No. आव दत म ड क न म 7 Name of Mandi / Place applied for 8 र य State 9 ज़ल District 10 तअस ल / त ल क Tehsil / Taluka 11 ल क / म ड Block / Mandi 12 दज Category य द आर त ( म णपऽ स न कर ) If, Reserved ( Attach certificate ) य द, वश ष ( म णपऽ स न कर ) If, Special ( Attach certificate ) स म य वग General अन स चत ज त Scheduled caste पव स नक Ex-serviceman पछड वग Backward म हल उधय म Women Entrepreneur आर त Reserved अन स चत जनज त Scheduled Tribe वश ष Special य ध वधव War Widow तर क म पर नभ र Dependent of Defense personnel वत स न न Freedom fighter श र रक प स अ म Physically Handicapped श त ब र जग र Educated unemployed 13 अ य द एकम ऽ व म य भ गद र स थ य नग मत स थ य सअक र स थ ( भ गद र वल ख / म त रन म क त स न कर ) Whether Sole Proprietor or Partnership Firm or Body Corporate or Cooperative Institution. (Attach copies of partnership Deed / power of Attorney) य द, एकम ऽ व म If, Proprietorship न म Name (न टर हलफन म स न कर ) ( Attach notarized affidavit ) ( क पय, ज ल ग ह ( \/ ) नश न लग य 3
4 ब स य द, भ गद र स थ ह ( भ गद र वल ख क त स न कर ) If Partnership ( Attach copies of partnership Deed ) अ धक र पऽ/ म त रन म Power of Attorney न म Name न म Name य द, नग मत स थ / सअक र स थ ( स थ अ त न यम क त स न कर ) If Body Corporate ( Attach copy of Articles and Memorandum of Association ) नद शकगण क न म Name of Directors श र तशत Share % द य द, सअक र स थ ( स थ प ज करण म णपऽ, म णपऽ स य तथ उप वध क त स न कर ) If Cooperative Institution ( Attach copy of the Certificate of Registration with By Laws ) Registration No कस क र क ड लर शप च हत ह Type of Dealership Required य द प हल स ड लर ह ( प ज करण म णपऽ स य त स न कर.) If already a Dealer ( ( Certificate of Registration No.) क ल नव श (. म 000 ) Total investment ( `. in `000 ) दक न क तल ऽ Shop Floor Area i. थ त Location ii. ग द म ऽ Godown Area iii. क य कत Staff iv. अ य Other नज़द क र व ट शन 18 Nearest railhead ( क पय, ज ल ग ह ( \/ ) नश न लग य थ क- वबय Whole-sale फ टकर- वबय Retail-sale म ख / य प रक / अ य Prime / Business / Other द न Both वग म टर Square Meter वग म टर ( वयम क / कर य क / द न Sq. Meters ( Owned / Hired / Both ) वबयक म क स य ( Salesman Numbers ) स य ( Numbers ) दर क. म. Distance Kms. 4
5 नज़द क व यरह उस 1 दर कल म टर. 19 ( दर, ब त बम म ) Nearest Warehouse ( Ascending order of distance ) 2 3 Distance दर Distance दर Distance Kms कल म टर. Kms कल म टर. Kms श ऽ म क य रत उव रक ड लर क स य स य Numbers 20 तथ उनक क ल व ष क वबय No. of Fertilizer Dealers operating in this Location and estimated total annual Sale य रय Urea म.टन MTs ड. ए. प. D.A.P. म.टन MTs एम.ओ. प. M.O.P. म.टन MTs अ य Others म.टन MTs 21 आव दक स थ क व त य प रक ज नक र Details of Business Operations of the Applicant firm. थत Location थ पन वष Year of establishment य प र क क र Line of Business सम व शत ऽ Area covered वबय कम च र स य No. of Salesman य द उव रक य प र म क य रत, य क क पन क न म एवम य क क पन क पछल 22 स ल क व ष क वबय If in Fertilizer Business specify Companies and Annual Off Take from each Company for the Last year उ प दन क म ऽ ( म.टन ) सम व शत क पन क न म Name of Company कब स Effective य रय Urea Product with Qty. ड.ए.प. D.A.P. एम.ओ.प. M.O.P. अ य Others ऽ Area covered उव रक य प र म क य रत स टर क प नय क न म, य द ह त उन क प नय क व त 23 ज नक र तथ व ष क वबय Name of Sister Concerns in Fertilizer Business ( If Any ) with details of Company (s) represented and annual off take स टर क प नय क क पन त नध क व ष क वबय Annual off take न म Names of Sister concern न म Name of the Company representative य रय Urea ड.ए.प. D.A.P. एम.ओ.प. M.O.P. अ य Others 5
6 आव दक स थ क गत त न वष क उव रक वबय म व ष क टन -ओवर 24 ( ब ल स श ट क म णत त / स स ट स रटन स ल न कर ) Annual Sales turn over in Fertilizers of the applicant firm for the last three years ( Attach certified Balance Sheet / Sales Tax Return ) उव रक वबय म व ष क टन -ओवर Annual Sales turn over म ऽ म. टन म Qty. in MT वष I Year-I वष II Year-II वष III Year-III म य (.ल ख म ) Value in `. lakhs) ब कर क न म Name of the Banker 25 ब क Bank थ न Place श ख Branch अक उ ट न बर A/c. No.. उव रक य प र क लए व य यव थ Financial Arrangement availed for Fertilizer Business व य यव थ Financial arrangement अम उ ट (. म `000 ) Amount ( Rs.`000 ) 1. गरव र न Pledge ह इप थक शन Hypothecation 3. श ध ओवर स ट Clean Overdraft 4. ल टर आफ ब डट Letter of credit 5. ब क ग र ट Bank Guarantee 6. अ य क ई Any other 27 ब ड ल मट करन क लय ब क क म ज न मन तथ स य रट द गय Margin Money and Security given to the Bank for availing Credit Limits व य यव थ Financial arrangement अम उ ट (. म `000 ) Amount (`.`000 ) 1. म ज न मन Margin Money 2. स य रट Security य आव दक ई कम ट स द त ह, य द ह Whether the applicant is Income-Tax payee. If yes प न न बर ( त स ल न कर ) PAN No.( Attach copy ) वष, तक अस स कय गय Year upto, which assessed इ कम-ट स रटन ( गत त न वष क त स ल न कर ) Income Tax returns ( Attach for last three years ) स स-ट स प ज करण व श Particulars of Sales Tax Registration. T I N No. ( Attach copy ) टन न बर ( त स ल न कर ) C S T No. ( Attach copy ) स.एसट न बर ( त स ल न कर ) 6
7 30 I II III अचल स प व वध र / भ ग द र -स थ क न म पर क य र. ( द त व ज म ण र व य रस द, नगरप लक ट स रस द, परट क स ल-ड ड क त लप स न कर ) Details of immovable property in the name of Proprietor / Partnership firm. ( With documentary proof in the shape of Revenue Receipts, Municipal Tax Receipts, Photocopy of sale deed of properties etc ). न म-प य त Nomenclature दक न / आ फस Shop / Office ग द म Godown(s) व ण यक / रह यश ल स Comml./ Res. Plots ब ष भ म ( एकड म ) IV Agri land ( In acre ) V मक न House (s) VI ल स Flat(s) VII अ यOthers( Pl.specify ) ल ट स ईज़ Plot Size पत / थत / सव न बर य अ य पअच न Address / Location survey No. or any other identification य द ह इप थक ट ड / ल ड Whether Hypothecated / pledged अन म नत म य (. 000) ज नक र द Estimated Value (Rs. 000) Give Details अन म दत व य अर स व य एशन म ण-पऽ स ल न कर Attach Valuation Certificate from Approved Valuer 31 ब. व. एफ. स ल. स अन म नत व ष क उव रक आफ-ट क Estimated Annual off take of Fertilizers from BVFCL April May June July August म ह Month म ऽ (म. टन म ) Quantity ( in MTs ) अ ल मई जन ज ल इ अग त September सत बर October अ टबर November नव बर December दस बर January February जनवर फरवर March म च Grand Total स पण य ग 7
8 य द य ह त ब.ज. / एल.स. त त कर सक ग ह / नह य द ह, ब.ज. / एल.स. द न क स म.... ( ब क स म ण-पऽ स ल न कर ) Will you be able to furnish BG/LC for supplies --- Yes / No If yes, the extent of BG / LC that can be given for Rs..... ( Attach Certificate from Bank ) क पन ड लर शप ध रक स आव दक क स बध व त ज नक र द ह / नह Details of the Applicant s relation having company dealership Yes / No स थ म क य रत आव दक क स बध गण व त ज नक र द Details of applicant s relations working in the organization न म Name पदन म Designation 35 य कभ आव दक क इस शअल कम डट ए ट / उव रक ( नय ऽण) आद श क अ तग त प न ट लग ह? ह / नह य द ह त व त ज नक र द Has the applicant suffered any penalty under the Essential Commodities Act and / or Fertilizer (Control )Order? Yes / No If yes, give details म / हम प करत ह क उपर ववरण स य ह, य द द गई ज नक र आग गलत प इ ज त ह I / we confirm that the particulars as given above are true. In case any information is found त ब. व. एफ. स. एल. ब धन क ए म व वव क स ड लर शप नर त करन क अ धक र ह ग. म incorrect even at subsequent stage, BVFCL management will have the sole discretion for / हम नय क स ए ड क ड श स क म नन क वचन बध ह. termination of dealership forthwith. I / we also undertake to abide by the terms and conditions of appointment. म / हम एतद र......क आपस ड लर शप क तहत यवह र We hereby authorize Mr...Managing partner करन क लए अ धबत करत ह और वयम क, य गत / अलग अलग ज म द र वहन करन to deal with you and bind ourselves individually and severally for any liability arising out this क ब य ह dealership. भ ग द रगण क न म Name s of Partners त र ख :- Date:- द तखत Signature आव दक क द तखत / Signature of the applicant ब क य भ ग द र Managing partner ( स थ क म हर ). (along with Seal of the firm). 8
9 स ल न प क सच List of enclosures :- न न ल खत प क अन म णत त.स गन कर Duly attested copies of the following documents are enclosed. ए.एफ. = आव दन कय ह SN प क सच Documents 1 Attested copy of State Sales Tax Registration Certificate-GSTIN No A.F. = Applied for ह / नह / ए.एफ. ल ग नह Yes / No / A.F Not Applicable 2 Attested copy of Central Sales Tax Registration Certificate C S T No 3 Attested copy of Permanent Account No PAN NO 4 Attested copy of Fertilizer Registration Certificate(Whole Sale)-FRC 5 Original affidavit for decalring status of Proprietor/Partner/Managing Director/Managing Partner/Director from Judicial Magistrate/Oath Commissioner/Notary Public of the Area as per sample copy enclosed Page No 10 6 Attested copy of Partnership Deed 7 Attested copy of Income Tax Returns along with Audited Annual Accounts/Statement of Profit & Loss A/c of Immediate Last Three Years of immediate last three years 8 Original NBank reference certificate on Bank s letter head with seal indicating Applicants Firms s CC A/c No. Credit facility & financial soundness. CC limit if any availed by the party from Bank 9 Original Recommendation letter from Dir. Of Agri of the State. In case of NE States. 10 Attested copy of ST/SC Caste Certificate 11 An attested of applicants Proprietor/All partners/managing Director/Managing Partner/Director to be pasted at appropriate place in dealership application One set extra to be pasted on Dealership Appointment Letter) Page No Identification & Address Proof, Attested copy of Applicants /Driving License/Phone Bill/Electricity bill or any other proof indicating Identification & Address. Signature with Applicant s Firm Seal 9
10 I,Shri.. S/o,D/oShri aged about..years, (Hindu/Muslim/Christian/Buddh) by religion, by profession business, a resident of (Place) do hereby make oath and solemnly affirm as follows: 1.That I am a bonafide Citizen of India 2.That I am having a permanent residence at.. 3.That,I am sole proprietor/partner/authorized signatory of the firm M/s (Alongwith complete postal address of firm) 4.That I shall abide by all the terms & conditions of BVFCL abide instructions of authorities issued time to time. 5.That, I shall be responsible for all acts and omissions committed on behalf of me or my firm by my staff/representative authorized by me in business dealing with M/s BVFCL and shall pay all the liabilities arising out of it. 6.This affidavit is made and sworn and will be treated as piece of documentary evidence to prove about my status as a sole proprietor/partner/ Authorized signatory of the aforesaid firm M/s..as stated above and shall be produced before the concerned authority. Place: Date: Deponent Declaration I do hereby declare that above said contents of statement are all true to the best of my knowledge and belief and nothing has been concealed therein. Identified by me Signature of Deponent Signature with Round Seal of Magistrate Oath Commissioner/Judicial Magistrate/Notary Public 10
11 पण प स भर ह आ ड लर शप आव दन-प स ब धत र य क य लय म त त करन च हय. Duly filed up Dealership Applications should be submitted to the state offices concerned of the following state. For Assam State: Brahmaputra Valley Fertilizer Corporation Ltd. General Manager (Marketing) Corporate Office, Namrup Marketing Division P.O-Parbatpur. Dist- Dibrugarh (Assam). Pin For Other N. E. States Brahmaputra Valley Fertilizer Corporation Ltd. House No. 21, ( Ground Floor ) Usha Nagar Path, Near Super Market Dispur GUWAHATI ( Assam ) For West Bengal & Sikkim Brahmaputra Valley Fertilizer Corporation Ltd. Flat No Harrington Mansion, 8, Ho Chi Minh Sarani Kolkata 71 West Bengal For Bihar & Jharkhand Brahmaputra Valley Fertilizer Corporation Ltd. C/o Shri Sunil Kumar Jha, L-i/I, S.K.Puri Boring Road PATNA (BIHAR.) 11
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