FORM-VI
[See Rule 10(1)]
APPLICATION FOR THE GRANT OF LICENCE TO SELL, STOCK OR EXHIBIT FOR SALE OR
DISTRIBUTE INSECTICIDES

To
The Licensing authority,
State of _______________

     1.  Full name and address of the applicant.____________________________
          _________________________________________________________.

     2.  Is the applicant a newcomer(Say "Yes" or " No")___________________

     3.  If yes, the name of the principals, if any, whom he represent ____________

     4.  [****]

     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 be obtained.

     4.  [****]

     7.  Situation of the dealer’s premises where the insecticide will be (a) stored; and
          (b) sold

     8.  The names of the 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 of my /our
                knowledge and belief, and no part thereof is false.

            b. I/we carefully have read the terms and condition of the licence and agree
                to abide by them.

                Name and address of the applicant(s) in block letters.
                 _____________________________________________________

Date:_________________
Place:___________________

Signature of the applicant.___________________

Remarks by the Licencing Authority