(FORM-VI-A) (See Rule 10(3A) APPLICATION FOR THE GRANT OF LICENCE TO STOCK AND USE RESTRICTED INSECTICIDE(S) FOR COMMERCIAL PEST CONTROL OPERATION(S) To The Licencing Authority, State of.... 1. Full Name of the applicant (Block letters) 2. Address; (i) Registered Office (ii) Zonal Office (iii) Premises for which application is made 3. Is the applicant already in business or newcomer 4. Qualifications of responsible technical person (i) Educational Qualification (ii) Training in pest control operations (iii) Experience in using restricted insecticides (Attach proof in respect of claims) 5. If in the trade, give full particulars of the names of restricted insecticides (s) handled and categories of operations undertaken, the period and the places at which the trade was carried on. 6. Quantity(s) of each restricted insecticide in possession on the date of application (Give details of places where it is stored). 7. Details of persons engaged or proposed to be engaged (Attach separate sheet duly authenticated). 8. Details of safety applications available along with antidotes and all other facilities required under chapter will be stored for use. 9. Situations of the branch offices and depots where the restricted insecticides will be stored for use. 10. Names of restricted insecticides which the applicant desires to use. 11. Category(s) applied for. 12. Particulars of the fees deposited. 13. Whether technical expertise approved by the Plant Protection Adviser to the Government of India for undertaking pest control operations (Attach Proof). 14. Whether permission obtained form Plant Protection Adviser to the Government of India for undertaking fumigation (attach Proof & Validity). Signature of the applicant Verification I......S/o.......do herby solemnly verify that to the best of my knowledge and belief the information given in the application and the annexure and statements/accompanying it, is correct and complete. 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 . Signature with Seal Place:.... Date...
