FORM XII
INTIMATION TO PERSON / LICENCEE FROM
WHOM SAMPLE IS TAKEN
[see rule 33]

To
_________________________________
_________________________________
_________________________________

I have this day taken from the premises of _____________________ situated at _________________ samples of the insecticide specified below for the purposes of test or analysis.

Date._________________                                                   Insecticide Inspector

Details of sample taken._________________________________

Date.________________                                                    Insecticide Inspector.