[FORM III] (See rule 9) Application for the grant of licence of manufacture Insecticides. 1. Name, address and status of the applicant: 2. Address of the premises where the manufacturing activity will be done: 3. Name of the insecticides with their Name of the Registration Date registration number and date for insecticides No. which manufacturing licence is applled-(enclose copies of certificate of registrations duly signed by the applicant.) 4. Whether any registration is provisional. If so give particulars: 5. Detail of full time expert staff Name Qualification Experience connected with manufacture and 1. testing of the Insecticides in the 2. above unit: 3. 6. Whether all the facilities required under Chapter VII 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 give 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 herewith. Date: Place: [Signature with seal]
