Insecticides Rules, 1971- Form IV

FORM IV

APPLICATION FOR RENEWAL OF LICENCE TO MANUFACTURE INSECTICIDES
[Rule 9(1)]

1. I/We _________________of ___________________hereby apply for the renewal of the licence to manufacture insecticide on the premises situated at ______________________ (licence No. and date to be given).

2. The other details *regarding the manufacture of the insecticide continue to remain the same.

3. Particulars of the fee deposited _________________________________

4. The licence is enclosed herewith.

Date_____________

Signature_______________

VERIFICATION

I_________________________ S/o ________________________ do hereby solemnly verify that what is stated above is true and correct to the best of my knowledge and belief.

I further declare that I am making this application in my capacity as - _____________________ (designation) and that I am competent to make this application and verify it, by virtue of __________________ a photo/ attested copy of which is enclosed.

Date:______________
Place:________________

Signature with seal__________________

*if there is any change in the details in manufacture or conditions of licence subject to which the licence is required to be renewed, the same may be indicated here.