GOVERNMENT OF WEST BENGAL FORM – C1
Application for Issue of Licence for FPS Dealership under
Photograph(s)
Compassionate Ground in respect of Individual person along with of the
Checklist applicant(s) in
[Vide clause 39 of the WBTPDS (M&C) order, 2024] Aadhaar
No field should be left blank. If not applicable, write “Not Applicable"
Authentication
Aadhaar (eKYC to be done through OTP to Aadhaar-linked mobile)
Mobile No. (to be validated through OTP)
E-Mail ID (to be validated through OTP)
Part-I (Details of previous dealership)
1. Code and Place of existing FPS dealership:
2. Existing/Old license No.
3. Licence renewed till which year:
4. Name of deceased/incapacitated dealer:
5. Date of demise/date of certificate regarding incapacitation:
6. In case of incapacitation, reason and details:
Part II (Details of applicant)
7. Name of the candidate/ applicant (as in Aadhaar):
8. Name of father/mother/husband:
9. Relation with deceased/incapacitated proprietor:
10. Date of birth:
11. Gender:
12 Caste :
13. Citizenship:
14. PAN of the candidate:
15. Aadhaar No.
16. Mobile Phone No.
17. eMail ID:
18. Residential address(es):
19. Permanent address(es):
20. Whether physically and mentally fit:
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21. HighestEducational qualification:
Part- III (Financial details)
22. Financial solvency of the candidate
a. In case account held in a Bank/Post Office
IFSC Bank Branch A/C type Deposit type A/C. Balance
Name Name (Single/Joint) (Savings/FD/TD/RD/ No. on the
Flexi) Date of
application
(INR)
(Add row for multiple accounts)
b. In case of Joint account enter the name of all joint account holders
Joint A/C. holder’s Name Is NOC given?
23. Family income per month from all sources other than FPS:
Part-IV (Existing Storage Godown and Office/Shop-Counter Details)
24. Full address of the Shop-cum-Godown as reflected Auto fetch
in last renewed license with
Dag No., Khatian No., Mouza, J.L. No., Village, Gram
Panchayat, Block, Police Station and PIN Code
(in case of rural area) or
Holding No., Street Name, Ward No.
Municipality, Police Station and PIN
Code (in case of Municipal Area):
25. Whether the same Shop-cum-godown would be in use now: Yes/ No
a) If no, then reason for such change:
b) Distance of offered shop-cum-godown from the existing shop-cum-godown:
(If ‘Yes’ then no further details is required.)
Details of the proposed shop-cum-godown:
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(If answer to point 25. is ‘No’ then to fill this)
26. Godown with separate Office/Shop Space: Yes/No
(If yes, then fill 26a, 26b., 26c., 26d.)
a. Full address of the Shop-cum-Godown with :
Dag No., Khatian No., Mouza, J.L. No., Village,
Gram Panchayat, Block, Police Station and Pin
Code (in case of rural area) or
Holding No., Street Name, Ward No.
Municipality, Police Station and Pin
Code (in case of Municipal Area)
b. In case of multiple compartments of godown (not more than 2):
Enter No. of godowns/chambers excluding shop-counter/office
Sl. Length Breadth (in Height Area (in Sq. Plinth height
No. (in ft) ft) (in ft) ft.) ( in inches)
Total Area-
c. Size of the shop-counter/office :
Length (in ft) Breadth (in ft) Area (in Sq. ft.) Plinth height ( in
inches)
d. Whether godown and shop-counter/office are adjacent & connected: Yes/No
e. Whether the godown or shop is opening to any other room/ premises, passage etc. : Yes/No
If answer to point 26. is ‘No’ then to fill 26e. & 26f.
f. Full address of the Shop-cum-Godown :
with Dag no., Khatian No., Mouza, J.L. No.,
Village, Gram Panchayat, Block, Police Station and
PIN Code (in case of rural area) or Holding No.,
Street Name, Ward No., Municipality,
Police Station and PIN Code (in case of Municipal Area)
g. Size of the shop-cum-godown (Area in sq.ft.):
Length Breadth (in Height Area (in Sq. Plinth height
(in ft) ft) (in ft) ft.) ( in inches)
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27. Boundary of the godown:
East
West
North
South
28. Whether the Shop-cum-godown has a verandah with shed to Yes/No
accommodate at least 5 (five) people, who may wait in the queue:
29. Structure of roof of the godown:
Structure of roof Select
a Made of concrete slab/brick slab
b Made of asbestos/tin sheet with coating of bitumen
c Made of asbestos/tin sheet without coating of
bitumen
Note: Kutcha or thatched roof is not allowed.
30. Structure of floor :
Structure of floor Select
a Complete in all respect including cement/tile finishing
b Floor is otherwise ready but tiles/cement finishing is not
done
c Floor is not ready at all
31. Structure of wall:
Structure of wall Select
Complete in all respect with brick/mortar/stone including
a
plaster
b Complete but all inner walls do not have plaster
c Wall is made of material other than brick/mortar/stone
d. Incomplete wall
32. Structure of Door:
Structure of door Select
a Complete in all respect including shutter
b Incomplete
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33. Whether delivery truck can reach the godown for unloading: Yes/No
If not, whether the godown is accessible by small carts for loading: Yes/No
34. Character of land of the premises :“Dokan or Godown/ Bastu or Vita(Homestead Category)/
convertible to Dokan or Godown under land Law/ Other than
as mentioned’.
Part-V (Nature of Possession of the Storage Godown and Office/Shop-Counter)
35 Nature of possession Select
a Sole Ownership
b Shared/Family property
c Long term rental/ Lease agreement
36. In case of ownership:
a. Mode of acquisition(Gift/Purchase/Inheritance/Others) :
b. No. and date of execution of Registered deed of
conveyance/purchase/gift in the name of applicant/
Mutation Certificate/Property tax receipt :
37. In case of property owned by a family member of the applicant(including shared ownership):
a. Name of the owner:
b. Relationship with the applicants/s:
c. Ownership document No. : ROR/Deed/Property Tax Receipt/Mutation Certificate/Others
d. Whether family member(s) has/have given NOC?
e. If shared, whether other co-owners have given NOC?
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38. Leased/Rental Possession
a. Name(s) of owner(s) of the premises :
b. No. and date of execution of Registered deed of conveyance / purchase /gift in the name of
applicant/ Mutation Certificate:
c. Extent of ownership: Absolute / Shared :
d. No. and date of execution of Registered or Notarized Lease Deed/ Tenancy or Rental Agreement
for at least 4 years/ leave & licence Agreement:
f. Period of lease/tenancy under registered agreement deed :
g. Whether expressly rented/leased for FPS as per deed :
Part-VI (Other details)
Prior experience of business, if any :
39. If yes, give details with nature and area of business:
40. Whether applicant is holding a license of FPS Dealer or Distributor :
or wholesaler in his name or he is a relative to a person as per
clause 2(1)(x) of the WBTPDS (M&C) Order, 2024, who already
have a dealer or Distributor or Wholesaler license.
If yes, give details.
41. Whether the applicant is a Flour Mill or a Rice Mill and its Owner in any capacity:
42. Whether applicant is a member of local bodies, local authority, Panchayati Raj Institutions,
Board or corporation, Commission or Member of Legislative Assembly or a Member of
Parliament during his tenure as such capacity:
43. Whether the applicant is a Dealer, whose License has been cancelled / terminated for
contravention of the provisions of the Act or the Control Order:
44. Whether the applicant is a Dealer, who earlier has resigned or voluntarily surrendered his
license:
45. Whether applicant is a person holding a post in the establishment of any :
State Government or Central Government or any authority
or body or institution of Local self-government established or
constituted by or under the Constitution or by any other law
made by the Parliament or a State Legislature or by notification
issued or order made by the Central Government or a State
Government
46. Whether applicant, partners, etc. ever been convicted under EC Act, 1955 :
or in any other criminal proceedings connected with essential
commodities or has/have litigation against the Department/Govt.
(If so, details thereof, else declaration in Annexure-I)
47. Whether involved in litigation against Govt. of WB or of India in :
any court of law
48. If yes, give details with case no. and name of court of law:
Declaration
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I/We certify that the statements above are true to the best of my/our knowledge and that for any
suppression of fact(s) detected later on, the licence granted to /us is liable to be cancelled.
Date:
Place:
........................................................................
Signature of Applicant/Authorized Signatory
Part-VI (Uploading section)
Checklist to Form C1
Checklist of documents to be uploaded with Application Form for engagement
on compassionate ground in respect of individual person
Part-I: Application fees
(to be fetched from GRIPS)
1. Application fees deposit challan
Part-II: Details of the Applicant
Upload- Preview
2. Identity proof of the Individual
[EPIC(S)/ Passport(s)]
Upload- Preview
3. Proof of residential address of the Individual
[EPIC/ Passport/recent Electricity Bill/Driving License]
4. PAN Card of Individual Upload- Preview
Upload- Preview
5. Proof of educational qualification of individual
[Certificate or Marksheet]
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Upload- Preview
6. Medical certificate of fitness of Individual from a Govt. Hospital
Upload- Preview
7. Family income certificate issued by the local authority
8. Caste Certificate (SC/ST/OBC)
9. Misc. Document (Adoption Deed/ Declaration etc.)
Part-III: Details of the deceased/incapacitated dealers
10. Death certificate of the deceased dealer Upload- Preview
11. Legal heirs certificate of the deceased/incapacitated Dealer Upload- Preview
issued by competent Authority and affidavit from the 1st Class
Magistrate
Upload- Preview
12. NOC in the form of affidavit from other eligible family members
in Annexure II.
13. Medical certificate of incapacitation in favour of the dealer issued Upload- Preview
by a Govt. Hospital, certifying reason of incapacitation in proper
format, in case of transfer of licence due to incapacitation.
Part-IV: Details of shop-cum-godown
Upload- Preview
14. A layout map showing clear boundary with dimensions showing
offered godown, office, shed for persons in queue, space for
unloading of stock of PDS commodities and approach road.
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15. In case of ownership (including NOC from family Upload- Preview
members)/shared ownership:
a) Photocopy of Record of Rights (Porcha)/ Registered Deed of
Conveyance/purchase/gift in the name of applicant/ Mutation
Certificate,
b) Document showing character of land as “Dokan or Godown/
Bastu or Vita(Homestead Category)/convertible to Dokan or
Godown under land Law/ Other than as mentioned”. if
Record of Rights is not produced
c) NOC of other co-owners (in case of shared ownership/family
members of the offered shop- cum-godown) in the form of
affidavit sworn before a Magistrate.
16. For leased/rented property:
a) Registered/Notarized Lease Deed or Tenancy or Rental
Agreement for at least 4 years or leave & licence Agreement,
b) Latest rent receipts, Upload- Preview
c) Registered Deed/RoR in the name of the land owner (or
lessor),
d) Any other proof of ownership, if ROR/Deed is not submitted.
Part V: Financial solvency
Upload- Preview
17. Proof of financial solvency [Account statement/Deposit Certificate
(FD/TD/ RD/Flexi)]/updated passbook issued by a recognized
bank/or Post Office as reflected on the date of application.
18. In case the aforesaid account/deposit is held jointly, NOC of such Upload- Preview
joint holder for investment in FPS Dealership
Part VI: Affidavit and others
Upload- Preview
19. Affidavit in Annexure-I format
Upload- Preview
20. Income Tax Return for last 3 FYs, if applicable
I/We certify that the statements above are true to the best of my/our knowledge and that for any
suppression of fact(s) detected later on, the application or offer letter or license granted to /us is liable to
be cancelled at any stage without assigning any reasons.
Date:
Place:
Signature of Applicant
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Acknowledgment
(System-generated pdf will also be sent to the email ID of the applicant)
Vacancy ID : Notification no.:
Time of Application:
Application ID :
Date of Application:
Name of the Applicant:
Mobile no.:
Residential Address: Village / Municipality / Municipal Corporation ......................... P.O. ..................,
P.S. ....................., District...................................
Place of vacancy: (Detailed location of the vacancy as published in the notification)
Type of vacancy: FPS (Compassionate) <pre-filled>
The application with above mentioned details has been submitted.
(This is a system-generated acknowledgment with no signature required)
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