FORM VII
[Rule 10(1)]

APPLICATION FOR RENEWAL OF THE LICENCE TO SELL, STOCK OR EXHIBIT FOR SALE OR DISTRIBUTE INSECTICIDES

To
The Licence Authority
State of_______________

I/we hereby apply for renewal of the licence to sell, stock or exhibit for sale or distribute insecticides under the name and style of __________________. The licence desired to be renewed was granted by the licensing authority for state of __________________ and allotted licence No._____________ on the _______________day of ______________20     .

The situation of the applicant's premises where the insecticides are / will be-
(a) stored and (b) sold

  (i)  I/we hereby declare that the situation of my /our premises where the
       insecticides are stored, and (b) sold, as stated below;

(a)_____________________________ (b) ___________________________

premises where insecticides are stored / Premises where insecticides are sold.

  (ii)  the insecticides in which I/we am/are carrying on business and the name of
        the principals whom I / we represent are as stated below :

full name and address of the applicant in block letters _________________________________________________________

Date:_____________________
Place:_____________________

Signature of applicant(s)______________