Food Odisha Portal

FORM 'A-I'

[See clause 6(1) and clause 18]

Application for Grant of License (Wholesaler /Retailer)

1. FPS's Name -

1. (a).Applicant's Name -

1. (b). Father/Husband's Name

1. (c). Whether SC/ST/SEBC/PH -

1. (d). FPS Designation -

2. Applicant's Profession

3. Applicant's Residence Address -

4. Whether, the applicant wants to act as -

4.(i)Type of license -

5. (a). Details of place where the applicant wants to act as wholesaler/retailer -

5. (b). Place of business

i). Plot No.

ii). Khata No.

iii). Mouza

iv). Street Address

v). Pin Code

vi). P.S.

vii). District

viii). Block

ix). Description of boundary *

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 klitr.)

vi) Is POS available?

5. (d). Ownership of premises

5. (e). Subcenter (if any)

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?

8. Quantity of each of the PDS commodities handled annually during last three years

Rice (in QTL)

Wheat (in QTL)

Kerosene Oil (in Ltr)

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

Rice (in QTL)

Wheat (in QTL)

Kerosene Oil (in Ltr)

10. Income-tax paid in the two years preceding the year of application

a. (i). Income-tax paid in the 1st year (in INR)

a. (ii). Copy of Acknowledgement Slip

b. (i). Income-tax paid in the 2nd year

b. (ii). Details

11. (a). Quantities of each of the PDS commodities in the possession of the applicant on the date of application

Rice (in QTL)

Wheat (in QTL)

Kerosene Oil (in Ltr)

11. (b). Complete address of places where the essential commodities are proposed to be stored

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 13(a).PDS distribution Through

Payment Information

Payment Mode -

Challan No. -

Challan Date -

Amount -

Bank Details

Bank Name

Branch Name

IFSC Code

Account No.

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 'A-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.

View Application Form

FORM 'A-I'

[See clause 6(1) and clause 18]

Payment Information

Bank Details