APPLICATION FOR ISSUE OF FAIR PRICE SHOP LICENSE

Applicant Personal Details

Full Name of the Applicant *

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Age of the Applicant (attach age proof in the enclosure section) *

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Father's/Husband's Name *

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Educational Qualification *

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Profession of the applicant, if any

Experience if any, in running business or in FPS items *

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Yes

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Please specify Experience *

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Applicant Address Details

Permanent Address

Address Line 1 *

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Address Line 2 *

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Address Line 3

Country

State

District

Postal / Zip Code

Present Address

Address Line 1 *

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Address Line 2 *

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Address Line 3

Country *

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State *

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District

Postal / Zip Code *

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Business Details

Name of the Shop/Business/Cooperative society (to be reflected in the license) *

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Location of the Business:

Street Name/Landmark/Sector *

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Village/Circle/Town/City

PO/PS *

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Country *

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State *

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District

Postal / Zip Code *

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Population of the location (Village/Circle) as per latest Census Date *

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Distance of the location from the nearest FPS in KM *

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Whether the place applied for is connected by Motorable road *

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Yes

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Whether the applicant will run the FPS independently or he/she will authorize other representative to run the FPS business on his/her behalf *

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Whether the Applicant has got land/pucca building in his/her name on the proposed site (if yes, attach documents in the annexure section) *

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Yes

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Whether financially sound or not (if yes, attach certificate in annexure section) *

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Yes

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Mention the name of the items/ foodgrains sought to purchase, sell or store for sale *

Item Name *

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Payment Details

Security Deposit *

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License Fee *

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Total Fee Payable *

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Declaration

I undertake to abide by the provision of Arunachal Pradesh (Licensing and Control) order and other instructions regulates of control of Fair Price Distribution Essential Commodities Act.

I also hereby certify that the information submitted by the above is true and correct to the best of my knowledge and behalf.