Insecticides Rules, 1971- Form III

FORM III
APPLICATION FOR THE GRANT OF LICENCE TO
MANUFACTURE INSECTICIDES
[Rule 9]

1. Name, address and status of the applicant
__________________________________________________________

2. Address of the premises where the manufacturing activity will be done
_______________________________________________________

3. Name of the insecticide with their registration number and date for which
manufacturing licence is applied for (enclose copies of certificate of registration
duly signed by the applicant).

Name of insecticide / Registration No./ Date

1_________________________________________________________
2_________________________________________________________
3_________________________________________________________

4. Whether any registration is provisional, if so, give particulars
______________________________________________________

5. Details of full time expert staff connected with the manufacture and testing of
the insecticides in the above unit:________________

Name / Qualification / Experience

1_________________________________________________________
2_________________________________________________________
3_________________________________________________________

6. Whether all the facilities required under Chapter VIII of the rules have been
provided. Give full details in a separate sheet.___________

7. Particulars of the fee deposited:_________

Signature of the applicant________________

VERIFICATION

I ________________S/o___________________do hereby solemnly verify that to the best of my knowledge and belief the information given in the application and the annexures and statements accompanying it, is correct and complete.

I further declare that I am making this application in my capacity as___________and that I am competent to make this application and verify it by virtue of ______________ a photo/ attested copy of which is enclosed here with.

Date:____________________
Place:____________________

Signature with seal._________________