APPLICATION FORM FOR FAIR PRICE SHOP

Type of Application

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License (Fresh Application)

Renewal

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Applicant Details

1.Name of the Fair Price Shop for which application is being made: *

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2. Address of proposed Fair Price shop *

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2.(i)District *

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3.Name of the applicant (In Block Letters): *

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3(i)Mobile Number *

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3(ii)E-Mail *

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4.Name of the applicant's father: *

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5.Does the applicant have a suitable house, room for running the shop: *

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a. Yes

b. No

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6.Permanent address of the applicant *

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6.(i)District *

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7.Postal address of the applicant *

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8.Is the applicant literate enough to maintain the stock/ distribution records of the fair price shop? *

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Yes

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8.(i)If no, who will maintain the distribution records? *

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8.(ii)If Yes, Evidence in support of working capacity shown above *

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9.Has the applicant previously been a fair price shop dealer? *

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Yes

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10 When and where? *

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11.Is the applicant already a grocery shop dealer? *

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Yes

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12 If so, location of the shop and type of foodstuff sold: *

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13.Whether the applicant is a disabled person? *

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Yes

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Declaration

I do hereby declare that the facts stated above are true and correct to the best of my knowledge and belief, and I undertake to be personally liable if the facts stated above are found to be incorrect or untrue in any way.

I Agree *