आवेदन-पत्र
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13.11 कमर्शियल पेस्ट कन्ट्रोल ऑपरेशन के स्टाक एवं उपयोग की अनुज्ञप्ति जारी करना
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FORM - II(1) GRANT OF LICENSE TO STOCK AND USE OF INSECTICIDES COMMERCIAL PEST CONTROL OPERATIONS [See Sub-rule (3A) of Rule 10] |
| 1. (a) Name of the Applicant * |
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(b) Address of Applicant * |
Max Length 240 characters |
(c) Email ID * |
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| 2.Whether the application is for * |
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| 3.M/s Firm Complete Address(Name,Complete Address etc.) * |
Max Length 250 characters |
| 4.Complete address (including name of the lane, PIN Code, etc.) of the premises, where the insecticide(s) shall be |
(a) Stored/Stocked * |
Max Length 250 characters |
(b) Sold or exhibited for sale or issued for use in case of commercial pest control operations: * |
Max Length 200 characters |
(c) Whether any of the above premises is situated in residential area (undertaking to be submitted) |
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(d) Whether food articles are also stored in any of the above premises (undertaking to be submitted) |
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| 5.(a) Qualification of the applicant/ the technical personnel under employment of the applicant |
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| (b) Whether fulfill minimum qualification as per Insecticide rules |
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| 6.Training (wherever applicable) |
(a) Name of the training/course |
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(b) Duration of training/course |
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(c) Certificate awarded, if any:(Enclose supporting documents) |
Max Length 250 characters |
| 7. Commercial pest control operations. |
(a) Address of registered, zonal and branch offices : * |
Max Length 240 characters |
(b) Address of the premises for which the license is applied for : * |
Max Length 240 characters |
(c) Whether approval of technical expertise obtained : * |
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(d) If yes, state reference number of approval : |
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Approval Date :(DD/MM/YYYY) |
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Approval validity : |
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(e) Name of restricted insecticides for which approved : * |
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(f) Name of responsible technical person : * |
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(g) Details of safety equipment, antidotes and all other essential facilities : * |
Max Length 240 characters |
| 8. For Commercial pest control operations, name of the insecticide(s) and its/their manufacturer/importer which the applicant intends to deal in the status of the principal certificate(s) in the format given below (Please enclose principle certificate(s) as per format Appended): |
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| 9. Full particulars of licence(s), if issued in the name of the applicant by any other state in the area of their jurisdiction |
Max Length 240 characters |
| 10. In case of renewal |
| (a) Please state licence number |
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| (b) Please state date of grant (DD/MM/YYYY) |
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| 11. Particulars of the application fee paid by the applicant |
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| 12. Any other relevant information |
Max Length 250 characters |
| 13. Manufacture Name(s) and Designation of the expert staff |
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14. मैं अपने प्रमाण-पत्र को अपने डिजिटल लॉकर में रखने की सहमति प्रदान करता हूँ। (असहमति के लिये अनटिक करें)
(यह सहमति/असहमति आवेदक से पूछ कर आवश्यक रूप से अपडेट की जाय) |
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| 15. Applicant Photo |
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: : Declaration : : a).I do hereby solemnly verify that the information given in the application and the annexures and statements accompanying it is correct and complete to the best of my knowledge and belief and that nothing has been concealed. I clearly understand that this license is liable to be cancelled, if any information, or part thereof, is found to be wrong, fake or false at any stage or any condition of license is violated.
b).I declare that we have adequate space and facilities to stock insecticides, so as to maintain their quality on shelf.
c).I shall not supply insecticide(s) to any distributor or dealer or person who does not have adequate space and facilities to stock them so as to maintain their quality on shelf under every circumstances. (for application for licence to manufacture)
d).I also declare that I shall not take possession of any stock without satisfying myself with the quality thereof.
e).I undertake that we shall forthwith inform any change in the responsible technical person.
f).I undertake that we shall forthwith inform any change in principle certificate to the licensing officer (not applicable for application for licence to manufacture)
g).I further declare that I am making this application in my capacity as --- and that I am competent to make this application and verify it by virtue of , an attested copy of which is enclosed herewith. I further declare that I shall abide by the conditions laid down in the license and failure to do so shall render the license liable to cancellation.
Signature of the applicant | | | |
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| आवश्यक दस्तावेज (आवेदक द्वारा स्वप्रमाणित) : |
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