FORM "A1"
MEMORANDAM OF INTIMATION
[See clause 8(2)]

(a) Name of the applicant (in English)

(b) Name of the concern (in English)

(c) Postal Address

(d) Email ID

(i) For Sale

(ii) For Storage

4. Detail of fertilizers and their sources as per Form 'O'

(i) Registration Fee (In Rs.)

(ii) Challan/Transaction No

(iii) Challan/Transaction Date (DD/MM/YYYY)

(iv) Bank Name

(i) Fertilizer Registration No

(ii) Date of Issue (DD/MM/YYYY)

(iii) Valid Upto (DD/MM/YYYY)

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