FORM IV
APPLICATION FOR RENEWAL OF LICENCE
TO MANUFACTURE INSECTICIDES
[Rule 9(1)]

     1.  I/We _____________________of _______________________hereby
          apply for the renewal of the licence to manufacture insecticide on the
          premises situated at ______________________ (licence No. and date to
          be given).

     2.  The other details *regarding the manufacture of the insecticide continue to
           remain the same.

     3.  Particulars of the fee deposited _________________________________

     4.  The licence is enclosed herewith.

Date_____________

Signature_______________

VERIFICATION

I_________________________S/o ________________________ do hereby solemnly verify that what is stated above is true and correct to the best of my knowledge and belief.

I further declare that I am making this application in my capacity as - _____________________ (designation) and that I am competent to make this application and verify it, by virtue of __________________ a photo/ attested copy of which is enclosed.

Date:______________
Place:________________

Signature with seal__________________

*if there is any change in the details in manufacture or conditions of licence subject to which the licence is required to be renewed, the same may be indicated here.