Format of Application

FORM – IV
[See Rules 4 and 7(vii)]

[To be submitted by the dealers to the State Pollution Control Board / Pollution Control
Committees]

1. a. Name of the dealer

b. Address

c. Telephone no.

d Mobile no.

e Fax no.

2. a. PAN No.

b. TIN no.

c. VAT no.

*IF APPLICABLE (AS PER THE CURRENT STATE TAX RULES, MANDATORY
TIN/VAT NUMBER IS REQUIRED ONLY IF THE ANNUAL TURNOVER OF THE
DEALER IS MORE THAN THE PRISCRIBED VALUE.)

Signature of the authorized person

Place:

Date:

Note:
• Dealer should submit the photocopies of Form – V as per the Rule 7
(IV) acknowledged by the manufacturers from last three years.
• Copy of registration of workshop/ shop granted by the Local Body.
• Copy of dealership granted by the authorized Battery manufacturer.