(FORM-VI) APPLICATION FOR THE GRANT OF LICENCE TO SELL, OR EXHIBIT FOR SALE OR DISTRIBUTE INSECTICIDES (Rule-10(I)) To The Licensing Authority, Place...... State of.... 1. Full Name and address of the applicant: 2. Is the applicant a newcomer? (Say "Yes" or "No") 3. If yes, the names of the principals, if any, whom he represents. 4. (***) 5. I enclose a certificate from the principals whom I represent or whom I intend to represent and the sources from which insecticides will be obtained. 6. (***) 7. Situation of the dealer's premises where the insecticide will be (a) stored; and (b) sold. 8. The names of 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 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(s) in block letters. Date...... Place....... Signature of the applicant. Remarks by the Licensing Authority.
