Food Odisha Portal

(*) 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) Details of place where the applicant wants to act as wholesaler/retailer

Maximum 200 characters allowed

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

6. Name of the PDS commodity/commodities which the applicant wants to deal with

Rice

Wheat

Kerosene

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 *

Rice (in QTL)

Wheat (in QTL)

Kerosene

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

Rice (in QTL)

Wheat (in QTL)

Kerosene

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 * Download Only .pdf document are allowed which is not more than 2MB

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

(b) ii. Copy of Acknowledgement Slip * Download 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. *

Rice (in QTL)

Wheat (in QTL)

Kerosene

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 * Download

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.

Edit Application

FORM 'A-I'

[See clause 6(1) and clause 18]

Other Information