Ayush Quality Mark – Cultivators / Collectors

1. Name of Cultivator/Collector* (Complete name as mentioned in document establishing the entity)

2. Address of Cultivator/Collector (Complete address with City, Pin Code & Sate/U.T., Country)

3. Address of Regd. Office/Office (if different from 2 above) (Complete address with City, Pin Code & Sate/U.T., Country)

4. Location(s) of the farms/collection areas where cultivation/collection activities are carried out (Complete address with City, Pin Code & Sate/U.T., Country)

5. Contact Details of Cultivator/ Collector (Give Telephone No., Mobile Nos., Email Id)

6. Legal Identity of Cultivator/Collector

7. Scale of Firm

8. Management of Cultivator/Collector* (Name & Designation of Top Management & Key Functionaries)

9. Whether the Cultivator/Collector has In-house laboratory for testing and assuring quality (Yes/No)* Select Yes No

10. Quality Control Personnel (Mention Names & Designations of Head of QA/ QC)

11. List of Medicinal Plants/Herbs/Botanicals As Raw/Starting Materials which are Cultivated/Collected

12. List of Medicinal Plants/Herbs/Botanicals as Raw/Starting Materials for which recognition is sought

13. Credentials in support of seeking recognition for products at 12. above

14. Compliance with organic standards like National Standard for Organic Production (NSOP) under National Program for Organic Production (NPOP) of APEDA or equivalent.

(Copy of certificate with scope to be attached with all details)

Organic Standards like National Standard for Organic Production (NSOP) under National Program for Organic Production (NPOP) of APEDA or equivalent

15. Adverse reporting/action by the regulatory/ certifying body, if any (Give details, if any action imposed)

16. Name and Address of Consultancy Firm/ Consultant engaged, if any for Any cultivation/collection related activities

17. Payment of Application Fees (Give details like Mode of Payment, Txn Id, Payment Date, Cheque No & Bank etc.)

18. Any other Information (Give additional information, if any, which the applicant may like to submit in support of and relevant the application)

19. Declaration –

It is hereby declared that the information, as provided above are true and the documents attached in support of the application pertain to us and are authentic. I undertake to inform the (PO), in case there is status change in respect of any information or the attached document.

* Application to be signed by Proprietor, Partner, Managing Director, Director, CEO etc. or in his absence, by his authorized representative.