Application For Grant Of certificate Of Registration/
Renewal As Medicinal Plants Collector(s)/Farmer(s)/Trader(s)
Applicant Name(In Block Letters)

First Name* Middle Name Last Name*
Father's/Husband Name

First Name* Middle Name Last Name*
Contact Person Name

First Name Middle Name Last Name
Status*
(Select Individual In Case of Farmer,Trader,Collector)		 :
Date Of Establishment (DD/MM/YYYY) :
Registration( Fresh / Renewal)* Fresh Renewal
Amount Of Fee Remitted* :
Address Type :
Addresses* :
Pin* :

Phone Fax Mobile
E-Mail :
Website :
Farmer's Bank Details

Bank Name* Bank Branch Address* MICR code of the Branch Bank Account Type : (Savings / Current)* Bank Account Number*
Place Of Registration* :
Registration Date(DD/MM/YYYY) :
Expiry Date(DD/MM/YYYY) :
                                                         DECLARATION

         I/We, declare that the information given above are true to the best of my knowledge and belief and that I/We shall abide by the Board Rules,the condition laid down in the certificate and any instruction (s) given by the Board from time to time regarding the conducting of business.

                     

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