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._________________