आवेदन-पत्र
|
13.1(B) रासायनिक कीटनाशक विक्रय लायसेन्स जारी करना(नवीन संशोधित)
|
FORM - IIGRANT OF LICENCE TO SELL, STOCK OR EXHIBIT FOR SALE OR DISTRIBUTE INSECTICIDES [See sub-rules (1) of rule 10] |
| |
| 1. (a) Name of the Applicant * |
|
(b) Address of Applicant * |
Max Length 240 characters |
(c) e-mail * |
|
| 2. Whether the application is for * |
|
| 3.Complete address (including name of the lane, PIN Code, etc.) of the premises, where the insecticide(s) shall be |
(a) Stored/Stocked * |
Max Length 180 characters |
(b)Sold or exhibited for sale operations: * |
Max Length 240 characters |
(c) Whether any of the above premises is situated in residential area(if yes then, undertaking need to be Attached) * |
|
(d) Whether food articles are also stored in any of the above premises (if yes then, undertaking need to be Attached) * |
|
| 4. (a) Qualification of the applicant/ the technical personnel under employment of the applicant |
|
|
| (b) Whether fulfill minimum qualification as per Insecticide rules |
|
| 5. Training (wherever applicable) |
(a) Name of the training/course |
|
(b) Duration of training/course |
|
(c) Certificate awarded, if any:(Enclose supporting documents) |
Max Length 240 characters |
| 6.In case of licence to sell/stock etc.name of the insecticide(s) and its/their manufacturer/importer which the applicant intends to deal in and status of the principal certificate(s) in the format give below (Please enclose principle certificate(s) as per format Appended) |
|
|
| 7. 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 |
| 8. In case of renewal |
| (a) Please state licence number |
|
| (b) Please state date of grant(DD/MM/YYYY) |
|
| 9. Particulars of the application fee paid by the applicant |
|
| 10. Any other relevant information |
Max Length 240 characters |
| 11. For Sale/Stock Name and Designation of the expert staff |
|
|
| 12. Address of Sell,Stock or Exhibit premises(Complete address along with PIN Code) * |
Max Length 200 characters |
| 13. M/s Firm Complete Name and Address(Name,Complete Address etc.) * |
Max Length 200 characters |
| 14. Pincode * |
|
| 15. Method of Payment * |
|
| Challan Details |
(i) Licence Fee (In Rs.) |
|
(ii) Challan No |
|
(iii) Challan Date (DD/MM/YYYY) |
|
(iv) Bank Name |
|
| 16. Applicant Photo |
|
: : Declaration : : a).I ---- s/d/o ---- 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 | | | |
|
|
| आवश्यक दस्तावेज (आवेदक द्वारा स्वप्रमाणित) : |
|