Firm Name Proprietor Name Email Firm Address Fertilizer Selling License No. Valid up to GST No. Adhar Card No. Mobile Whatsapp (Please provide correct mob. & whatsapp number, because all future communication will be initiated on these numbers only) Business Details Company Name Agencies Name Omex business plan for current year (Please tick mark in appropriate box) Up to Rs. 50,000/-Rs. 50,000-1 lakhRs. 1 - 2 LakhAbove Rs. 2 Lakhs Self Declaration I hereby declare that, the above given details and information is correct and true to my knowledge. I would liketo go ahead for Omex Preferred Dealership. Copy attached 1. Fertilizer Selling License 2. GST Certificate 3. Owner Adhar Card