FORMAT/MKT/NMP/017-B Form No.

:- 0000

पु वेल फ टलाइज़र काप रे शन ल मटे ड

Brahmaputra Valley Fertilizer Corporation Limited
( A Government of India Undertaking )
Marketing Division, Corporate Office – Namrup
P.O. Parbatpur PIN – 786623 Distt. Dibrugarh (Assam)
www.bvfcl.com, e-mail: marketing@bvfcl.co.in, marketing_it@bvfcl.co.in

सामा य वग के लए आवेदनप शु क
Application form Fee for General category …… Rs. 100.00
भु गतान ारा डी.डी न. ................ दनांक ............ बक .............................................
Paid by :- DD No …………….. Date ………. Bank ……………………………………
नगद भु गतान ारा रसीद ................. दनांक ............
Paid by Cash:- M.R. No. ……………. Date …………….
अनु सू चत जा त / अनु सू चत जनजा त के लए आवेदनप शु क .......... नल
(कृ पया, जा त का माण-प सं गन करे )
Application-form Fee for SC / ST category …… Nil
( On production of copy of Caste Certificate ) जार कता अ धकार
पदनाम
Issuing officer
Designation

डीलर शप आवेदनप
DEALERSHIP APPLICATION
(आवेदक इसे ना भरे - केवल कायालय योग के लए)
( Not to be filled by the Applicant – OFFICE USE ONLY )
1. आवेदक सं था का नाम
Name of the Applicant firm ...............................…………………………………..
2. वग Category ……………………………………..
3. रा य State ……………………………………..
4. िज़ला District …………………………………….
5. त सील / ता लु का Tehsil / Taluka ……………………………………..
6. लाक / म डी Block / Mandi ……………………………………..
7. म डी / थान Mandi / Place applied ……………………………………..
8. अनु मा नत वा षक आ टे क(मे.टन) Estimated Annual Off Take(MTs) ….........................

(Please read carefully and fill up all the columns. Incomplete applications are liable to be rejected.)
1.
 Attested Passport size Coloured Photographs to be pasted
with their Names & status of Dealership applicant(s)

आवेदनकता संःथा का नाम ................................................................................

Name of the Firm : M/s ………………………………………………………………….

A. Proprietor / CMD / MD / Managing Partner of the applicant Firm

आवेदनकता संःथा के एकमाऽ ःवामी का नाम

Affix
Passport
size
coloured
photograph
with name
below

B. Partners / Directors of the Applicant Firm

आवेदनकता संःथा के भािगदार / िनदे शकगणो के नाम

Affix Affix Affix Affix Affix

Passport Passport Passport Passport Passport
size size size size size
coloured coloured coloured coloured coloured
photograph photograph photograph photograph photograph
with name with name with name with name with name
below below below below below

Affix Affix Affix Affix Affix

Passport Passport Passport Passport Passport
size size size size size
coloured coloured coloured coloured coloured
photograph photograph photograph photograph photograph
with name with name with name with name with name
below below below below below

Affix Affix Affix Affix Affix

Passport Passport Passport Passport Passport
size size size size size
coloured coloured coloured coloured coloured
photograph photograph photograph photograph photograph
with name with name with name with name with name
below below below below below

2
 आवेदनकता संःथा का नाम
1
Name of the Applicant Firm

पऽाचार के िलये पूरा पता

2
Postal Address
3 पन कोड न बर PIN code No.
टे िलफोन एस.ट .ड कोड न बर स हत
4
Tele. No. with STD code No.
5 मोबाइल न बर Mobile No.
6 फै स न बर Fax No.
आवे दत मंड का नाम
7
Name of Mandi / Place applied for
8 रा य State
9 ज़ला District
10 तअसील / ता लुका Tehsil / Taluka
11 लाक / मंड Block / Mandi
दजा Category सामा य वग आर त वशेष
General Reserved Special
य द आर त अनुसिू चत जाित अनुसिू चत जनजित युध वधवा
( ूमाणपऽ सं न करे ) Scheduled caste Scheduled Tribe War Widow

पूव सैिनक ूितर किम पर िनभर

If, Reserved
( Attach certificate ) Ex-serviceman Dependent of Defense personnel
12
शार रक प
य द, वशेष पछडा वग ःवतं ा सेनानी से अ म
Backward Freedom fighter
( ूमाणपऽ सं न करे ) Physically
Handicapped

If, Special म हला उधयिम

( Attach certificate ) Women िश त बेरोजगार
Entrepreneur Educated unemployed

य द एकमाऽ ःवामी या भािगदार संःथा या िनगिमत संःथा या सअकार संःथा

( भािगदार वलेख / मु तारनामा क ूित सं न करे )
13 Whether Sole Proprietor or Partnership Firm or Body Corporate or Cooperative
Institution. (Attach copies of partnership Deed / power of Attorney)
अ य द, एकमाऽ ःवामी नाम
If, Proprietorship Name

(नोटर हलफनामा सं न करे )

( Attach notarized affidavit )
( कृ पया, जो लागु हो ( \/ ) िनशान लगाये
3
 य द, भािगदार संःथा हे
( भािगदार वलेख क ूित नाम
सं न करे )
ब If Partnership Name
( Attach copies of partnership
Deed )
अिधकार पऽ/ मु तारनामा नाम
Power of Attorney Name
य द, िनगिमत संःथा/ सअकार संःथा ( संःथा अंतिनयम क ूित सं न करे )
If Body Corporate ( Attach copy of Articles and Memorandum of Association )
शेेर ूितशत
िनदे शकगणो के नाम Name of Directors
स Share %

य द, सअकार संःथा –
द ( संःथा पंजीकरण ूमाणपऽ, ूमाणपऽ सं या तथा उप वधी क ूित सं न करे )
If Cooperative Institution –
( Attach copy of the Certificate of Registration with By Laws ) Registration No.
कस ूकार क ड लरिशप चाहते है थोक- वबय फुटकर- वबय दोनो
14
Type of Dealership Required Whole-sale Retail-sale Both
य द प हले से ड लर है
15 ( पंजीकरण ूमाणपऽ सं या ूित सं न करे .)
If already a Dealer
( ( Certificate of Registration No.)
कुल िनवेश ( . मै ‘000 )
16
Total investment ( `. in `000 )
दकान
ू का तल ेऽ वग मीटर
Shop Floor Area Square Meter
i. ःथित ूमुख / यापा रक / अ य
Location Prime / Business / Other
ii. गोदाम ेऽ वग मीटर ( ःवयम का / कराये का / दोनो
17
Godown Area Sq. Meters ( Owned / Hired / Both )
iii. कायकता वबयकिम क सं या
Staff ( Salesman Numbers )
iv. अ य सं या
Other ( Numbers )
नज़द क रे वे ःटे शन दरू क. मी.
18
Nearest railhead Distance Kms.
( कृ पया, जो लागु हो ( \/ ) िनशान लगाये
4
 नज़द क वेयरहाउस 1 दरू कलोमीटर.
( दरू , ब ते बम मे ) Distance Kms
2 दरू कलोमीटर.
19
Nearest Warehouse Distance Kms
( Ascending order of distance ) दरू कलोमीटर.
3 Distance Kms
शेऽ मे कायरत उवरक ड लरो क सं या सं या Numbers
तथा उनका कुल वा षक वबय यु रया Urea मे.टन MTs
20 No. of Fertilizer Dealers operating in ड . ए. पी. D.A.P. मे.टन MTs
this Location and estimated total
annual Sale एम.ओ. पी. M.O.P. मे.टन MTs
अ य Others मे.टन MTs
आवेदक संःथा क व त् यापा रक जानकार Details of Business Operations of the
Applicant firm.
समावेिशत
ःथापना वष वबय कमचार
ःथती यापार का ूकार ेऽ
21 Year of सं या
Location Line of Business Area
establishment No. of Salesman
covered

य द उवरक यापार मे कायरत ्, ू येक क पनी का नाम एवम ू येक क पनी का पछले
साल का वा षक वबय If in Fertilizer Business specify Companies and Annual Off Take
from each Company for the Last year
उ पादनो क माऽा ( मे.टन ) समावेिशत
क पनी का नाम कब से Product with Qty. ेऽ
22 Name of Company Effective यु रया ड .ए.पी. एम.ओ.पी. अ य Area
Urea D.A.P. M.O.P. Others covered

उवरक यापार मे कायरत िसःटर क पिनयो के नाम, य द हो तो उन क पिनयो क व त

जानकार तथा वा षक वबय Name of Sister Concerns in Fertilizer Business ( If Any )
with details of Company (s) represented and annual off take
िसःटर क पिनयो के क पनी ूितिनधी का वा षक वबय Annual off take
23 नाम नाम
यु रया ड .ए.पी. एम.ओ.पी. अ य
Names of Sister Name of the Company
Urea D.A.P. M.O.P. Others
concern representative

5
 आवेदक संःथा के गत तीन वष का उवरक वबय मे वा षक टन-ओवर
( बेलस शीट क ूमा णत ूित / से स टे स रटन संल न करे )
Annual Sales turn over in Fertilizers of the applicant firm for the last three years
( Attach certified Balance Sheet / Sales Tax Return )
24 उवरक वबय मे वा षक टन-ओवर वष ् – I वष ् – II वष ् – III
Annual Sales turn over Year-I Year-II Year-III
माऽा मे. टन मे Qty. in MT
मू य ( .लाखो मे) Value in `. lakhs)
बकर ् का नाम Name of the Banker
बक Bank ःथान Place शाखा Branch अकाउं ट न बर A/c. No..
25

उवरक यापार के िलए व ीय यवःथा

Financial Arrangement availed for Fertilizer Business
व ीय यवःथा Financial arrangement अमाउं ट ( . मे `000 ) Amount ( Rs.`000 )
1. िगरवी र ना Pledge

26 2. हाइपोिथकेशन Hypothecation
3. शुध ओवर सा ट Clean Overdraft
4. लेटर आफ बे डट Letter of credit
5. बंक गारं ट Bank Guarantee
6. अ य कोई Any other
बे ड िलिमट ूा करने के िलये बक् को मा जन मनी तथा िस यु रट द गयी
Margin Money and Security given to the Bank for availing Credit Limits
27 व ीय यवःथा Financial arrangement अमाउं ट ( . मे `000 ) Amount (`.`000 )
1. मा जन मनी Margin Money
2. िस यु रट Security
या आवेदक ई कम टे स दे ता है , य द हा
Whether the applicant is Income-Tax payee. If yes
पेन न बर (ूित संल न करे )
PAN No.( Attach copy )
28
वष, तक असेस कया गया
Year upto, which assessed
इ कम-टे स रटन ( गत तीन वष क ूित संल न करे )
Income Tax returns ( Attach for last three years )
से स-टे स पंजीकरण ् विश Particulars of Sales Tax Registration.
T I N No. ( Attach copy )
29 टन न बर ( ूित संल न करे )
C S T No. ( Attach copy )
सी.एसट न बर (ूित संल न करे )

6
 अचल स प ःव वधार / भागीदार -संःथा के नाम पर का योरा. ( दःतावेजी ूमाण –
रे वे यु रसीद, नगरपािलका टे स रसीद, ूापरट क सेल-ड ड क ूितिलपी सं न करे )
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 ).

30 पता / ःथती /
यद अनुमािनत मू य
लाट सव न बर या
हाइपोिथकेटे ड / ( . ’000)
नाम-प यित साईज़ अ य पअचान
ले ड जानकार दे
Nomenclature Address /
Plot Whether Estimated Value
Location survey
Size Hypothecated (Rs. ’000)
No. or any other
/ pledged Give Details
identification
दकान
ू / आ फस
I
Shop / Office
II गोदाम Godown(s)
वा ण यक / रहायशी
III ला स Comml./ Res.
Plots
ब ष भूिम ( एकड मे )
IV
Agri land ( In acre )
V मकान House (s)
VI ले स Flat(s)
VII अ यOthers( Pl.specify )
अनुमो दत वे युअर से वे युएशन ूमाण-पऽ संल न करे Attach Valuation Certificate from Approved
Valuer
बी. वी. एफ. सी िल. से अनुमािनत ् वा षक उवरक आफ-टे क
Estimated Annual off take of Fertilizers from BVFCL
माह Month माऽा (मे. टन मे) Quantity ( in MTs )
April अूेल
May मई
June जून
July जुलाइ
August अगःत
31 September िसत बर
October ु
अ टबर
November नव बर
December दस बर
January जनवर
February फरवर
March माच
Grand Total स पूण योग
7
 या ूदाय हे तु बी.जी. / एल.सी. ूःतुत कर सकगे – हा / नह य द हा, बी.जी. / एल.सी.
दे ने क सीमा . .................................................. ( बक से ूमाण-पऽ संल न करे )
32 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 पनी ड लरिशप धारक से आवेदक के स बध – व त जानकार दे हा / नह
33
Details of the Applicant’s relation having company dealership Yes / No

संःथा मे कायरत ् आवेदक के स बधीगण ् – व त जानकार दे

Details of applicant’s relations working in the organization
34 नाम Name पदनाम Designation

या कभी आवेदक को इसिशअल कमो डट ए ट / उवरक (िनयंऽण) आदे श के अंतगत पेन ट

लगी हे ? हा / नह य द हा तो व त जानकार दे
35
Has the applicant suffered any penalty under the Essential Commodities Act and / or
Fertilizer (Control )Order ? Yes / No If yes, give details

मे / हम पु करते हे क उपरो ् ववरण स य हे , य द द गई जानकार आगे गलत पाइ जाती हे

I / we confirm that the particulars as given above are true. In case any information is found तो
बी. वी. एफ. सी. एल. ूब धन को ए मेव ववेक से ड लरिशप िनरःत करने का अिधकार होगा. मे
incorrect even at subsequent stage, BVFCL management will have the sole discretion for /
हम िनयु के स एंड कंड शंस को मानने को वचन बध ् हू .
termination of dealership forthwith. I / we also undertake to abide by the terms and conditions
of appointment.
मे / हम एतद ारा ौी ................................................को आपसे ड लरिशप के तहत यवहार
We hereby authorize Mr.………………………………………………………..Managing partner
करने के िलए अिधबत करते हे और ःवयम को, य गत / अलग अलग ज मेदार वहन करने
to deal with you and bind ourselves individually and severally for any liability arising out this
को बा य हे
dealership.

भागीदारगणो के नाम Name’s of Partners दःतखत Signature

1. …………………………………
2. …………………………………
3. …………………………………
4. …………………………………

आवेदक के दःतखत / Signature of the applicant

ूब क य भागीदार Managing partner
( संःथा क मोहर ). (along with Seal of the firm).
तार ख :-
Date:-
8
संल न प ो क सू ची List of enclosures :-
न न ल खत प ो क अनु मा णत त.सं गन करे
Duly attested copies of the following documents are enclosed.
ए.एफ. = आवेदन कया हे A.F. = Applied for

SN हा / नह / ए.एफ.
प ो क सू ची Documents लागू नह
Yes / No / A.F
Not Applicable
1 Attested copy of State Sales Tax Registration Certificate-GSTIN No
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 Passport size coloured photograph of applicants
Proprietor/All partners/Managing Director/Managing Partner/Director
to be pasted at appropriate place in dealership application One set
photograph extra to be pasted on Dealership Appointment Letter) Page
No 2.
12 Identification & Address Proof, Attested copy of Applicants
Passport/Driving License/Phone Bill/Electricity bill or any other proof
indicating Identification & Address.

Signature with Applicant’s Firm Seal

9
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
पू ण प से भरा हु आ डीलर शप आवेदन-प स बि धत रा य कायालय मे तु त करना चा हये.

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- 786623.

For Other N. E. States

Brahmaputra Valley Fertilizer Corporation Ltd.
House No. – 21, ( Ground Floor )
Usha Nagar Path ,
Near Super Market
Dispur
GUWAHATI – 781006 ( Assam )

For West Bengal & Sikkim

Brahmaputra Valley Fertilizer Corporation Ltd.
Flat No. 13 – 14
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 – 800001 (BIHAR.)

11