FORM VI (See rule 10(1)) Application for the Grant of Licence to sell, stock or exhibit for Sale of Distribute Insecticides To The Licencing Authority State of ........ 1. Full Name and Address of the applicant 2. Is the applicant a new comer? (Say 'Yes' or 'No') 3. If yes, the names of the principles, if any , whom he represents. 4. If the applicant has been (i) in the trade, give full particulars of the names of insecticides handled the period and the place's at which the trade was carried on, and the principles whom he represented. (ii)also give the quantities handled during the past two calendar years (a) (b) 5. I enclose a certificate from the principals whom I represent or whom I intend to represent and the source/sources from which insecticides will to obtained 6. Quantities of each insecticides (in tones) in my/our possession on the date of application (at the sale depot and in godowns attached thereto). 7. Situation of the nearest premises where the insecticides will be (a) stored and (b) sold 8. The name of insecticides in which the applicant desires to carry on business 9. Full particulars of licence issued in his name by other State Government, if any in their area. 10. I have deposited the licence fee. Treasury Challan No.......... Sub-Treasury 11. Declaration. (a). I/We declare that the information given above is true to my/our knowledge and belief, and no part thereof is false. (b) I/We carefully has read the terms and conditions of the licence and agrees to abide by them Signature of the applicant Name and address of the applicant(s) in block letters Date : Place: Remarks by the Licencing Authority
