1. a. Name, address and status of the applicant.________________________
b. Category of the industry SSI/DGTD/MRTP/FERA/others._____________
2. Address of the premises where the manufacture will be done._____________
(i) In the case of import please state:
(ii) In the case of manufacture please state:
Whether the insecticide is meant for domestic consumption or for export or for both._________________________________________________
5. In the case of formulation, the sources of supply of technical grade material and its status of registration.
6. Chemical Composition.____________________________
7. Toxicity of the products to human beings, wild life, aquatic animals (toxicological
data to be enclosed as per details specified by the Registration Committee).
11. Seven copies of the proposed labels and leaflets (including all printed or graphic
matter which will accompany the package containing the insecticide) as per the insecticide
Signature of the applicant.__________________
I ____________________S/o ______________________do hereby solemnly verify that to the best of my knowledge and belief the information given in the application and the annexure 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 herewith.
Note : The application form including the verification portion must be signed in case of an individual, by the individual himself or a person duly authorized by him; in case of Hindu undivided family, by the karta; in case of a partnership firm, by the managing partner, in case of a company, by a person duly authorized in the behalf by the Board of Directors and in any other case, by a person incharge of or responsible for the conduct of the business.One Self addressed stamped envelope and one stamped envelope must be enclosed along with the application.