FORM XIV
MONTHLY RETURN OF SALES OF INSECTICIDES MADE TO THE BULK CONSUMERS OF THE STATE OF ___________________ FOR THE PERIOD FROM _____________ TO _________20_________
[Rule 15]

Sl. No.

Name of the insecticides with its brand name strength and type of formulation

Manufactured by

Batch No.

Date of expiry

Name of the purchaser with full address

Licence No. of purchaser

Size of pack

No of packs sold

Qty.

                   
                   
                   

* In case of bulk consumer give number and date of the order.

Signature_______________

Verification

I ____________________________do hereby verify that what is stated above is true to the best of my knowledge and belief based on information derived from the records. I further declare that I am competent to and verify this statement in my capacity as _________ (designation)

Signature__________________

Name____________________
Seal_____________________