All * marked fields are mandatory.
FORM 'A-I'
[See clause 6(1) and clause 18]
Application for Grant/Renewal/Reissue of License (Wholesaler /Retailer)/ Issue of duplicate copy of License (Wholesaler /Retailer)
1. Applicant's Name:* 1.(a) Father/Husband's Name:
1.(b) Whether SC/ST/SEBC/PH: 2. Applicant's Profession:*
3. Whether, the applicant wants to act as:* 4. Applicant's Residence Address: * (Maximum  200  characters allowed)
5.(a).I Details of place where the applicant wants to act as wholesaler/retailer: (Maximum  200  characters allowed) 5.(a).II Type of License:
5.(b) Place of business: *
(i). Plot No.: (ii). Khata No.:
(iii). Mouza: (iv). Street Address: (Maximum  200  characters allowed)
(v). Pin Code.: (vi). P.S.:
(vii). District: (viii). Block:
(ix). Description of boundary: *
To the East North West South
5.(c) Nature of premises:
(i) Building: (ii) Roofing:
(iii) Is compound wall available ? (iv) Is underground storage available ?
(v) Capacity (in kilolitre):* (vi) Is POS available ? :
5.(d) Ownership of premises :
5.(e) Subcenter (if any) : (Maximum  200  characters allowed)
Select Year :
6. Name of the PDS commodity/commodities which the applicant wants to deal with: 7. Did the applicant hold a license on any previous occasion?
7.(a) If Yes, give particulars including its suspension or cancellation, if any.: * (Maximum  200  characters allowed)
8. Quantity of each of the PDS commodities handled annually during last three years :*

9.Quantity of each of the PDS commodities likely to be handled during the current year:

10. Income-tax paid in the two years preceding the year of application.
(a).i Income-tax paid in the 1st year : Rs. (a).ii Copy of Acknowledgement Slip : Only .pdf document are allowed which is not more than 2MB *
(b).i Income-tax paid in the 2nd year : Rs. (b).ii Copy of Acknowledgement Slip : Only .pdf document are allowed which is not more than 2MB *
11.(a) Quantities of each of the PDS commodities in the possession of the applicant on the date of application. :*

11.(b)Complete address of places where the essential commodities are proposed to be stored: (Maximum  200  characters allowed)
12. Whether electric connection is available in the place where fair price shop is proposed to function :* 13. Whether internet connection is available in the proposed fair price shop to run the POS device :
Other Information
Mobile No.* Aadhaar/Enrollment Number*
Photograph of applicant :* FPS Code :
  I declare that the quantities of each of the essential commodities specified above are in my possession this day and are held at the places noted above.
I have carefully read the conditions of license given in FORM 'B-I' appended to the Orissa Public Distribution System (Control) Order, 2016 and I agree to abide by them.
I declare that the data/information furnished by me in the application are true and correct to the best of my Knowledge and belief.