FORM - VI See Rule 10 (1) APPLICATION FOR THE GRANT OF LICENCE TO SELL, STOCK OR EXHIBIT FOR SALE OR DISTRIBUTE INSECTICIDES To The Licencing Authority Union Territory of Pondicherry. 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 principals if any, whom he represents. 4. I enclose certificate from the principals whom I represent or whom intend to represent and the sources from which insecticides will be obtained. 5. Situation of the Dealer's premises where the insecticide will be a) stored and b) sold 6. The names of insecticides in which the applicants desires to carry on business. 7. Full particulars of licence issued in his name by other state Governments, if any, in their area. 8. I have deposited the licence fee Treasury Challan No. Sub Treasury/Bank 9. 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 have read the terms and conditions of the Licence and agree to abide by them. Name and address of the applicant in Block Letters. Signature of the applicant Place : Date : Remarks by the Licencing authority.
