FORM III

(On Letterhead of the Licensing Officer)

LICENCE TO MANUFACTURE INSECTICIDES

[See sub-rule (3) of rule 9]
Or
LICENCE TO SELL, STOCK OR EXHIBIT FOR SALE OR DISTRIBUTE INSECTICIDES,
[See sub-rules (4) of rule 10]
Or
STOCK AND USE OF INSECTICIDES FOR COMMERCIAL PEST CONTROL OPERATIONS
[See sub-rules (3A) of rule 10]
(Separate licence to be issued for manufacture/sale, stock etc. / pest control operations)

1. License Number _________________

License to manufacture / sell, stock or exhibit for sale or distribute insecticide(s) / carrying out commercial pest
control operations in the premises situated at

______________________________________________________________________________

(Complete address alongwith PIN Code)

is granted to M/s (Name, Complete Address, e-mail etc.,)

________________________________________________________________

as specified hereunder: -

Sl. No. Particulars Number of Date of grant Validity of

of the Certificate of of Licence,
insecticide Registration Licence wherever
applicable
1 2 3 4 5

2. The insecticide(s) shall be manufactured / sell, stock or exhibit for sale or distribute insecticide / commercial
pest control operations under the direction and supervision of the following expert staff:
a) For manufacture: Name(s) and designation of the expert staff (Insecticide wise, if any); and
b) For sale / stock / pest control operations: Name and designation of the expert staff

3. The licence is subject to such conditions as may be specified in the rules for the time being in force under the
Insecticides Act, 1968 as well as the conditions on the certificate of registration and others as stated below.

Signature of the Licensing Officer Seal

CONDITIONS

1. This licence shall be displayed in the prominent place in the premises for which the licence is being issued and
shall be produced for inspection as and when required by an Insecticide Inspector, licensing officer or any
other officer authorised by the Government in this regard.
2. Any change in the name of the expert staff, named in the licence, shall forthwith be reported to the licensing
officer.

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3. The licensee shall scrupulously comply with each and every condition of registration of the insecticide(s),
failing which the licence is liable to be cancelled.

4. No insecticide shall be sold or exhibited for sale or distributed or issued for use in commercial pest control
operations except in packages approved by the Registration Committee from time to time.

5. If the licensee wants to manufacture / sell, stock or exhibit for sale or distribute / stock and use for commercial
pest control operations, any additional insecticide, he may apply to the licensing officer for addition in the
licence for each such insecticide on payment of the prescribed fee.
6. For pest control operations an application for the renewal of the licence shall be made as laid down in sub-
rule (3A) of rule 10 of the Insecticides Rules, 1971.
7. The licensee shall comply with the provisions of the Insecticides Act, 1968, and the rules made there under
for the time being in force.

8. The licence also authorizes the storage and stocking of insecticide(s) manufactured at the licensed premises,
in the factory premises for sale by way of wholesale dealing by the licensee.
9. The licensee shall maintain the record of ‘date expired insecticides’ separately in the format as per Appendix
A.
10. The licensee shall maintain the record of sale /distribution of insecticides in the format as per Appendix B and
shall submit monthly return to the Licensing Officer.

11. The licensee shall maintain the stock register for technical and formulated products separately as per
Appendix C1 and C2, respectively. (For manufacturer only)

12. The licensee shall submit the monthly return for technical grade and formulated insecticides separately as per
Appendix D1 and D2, respectively. ( For manufacturer only)

13. The licensee shall maintain a record of periodical medical examination of persons engaged in connection with
insecticides as per Appendix E.

14. All the registers are to be kept under secured custody by the Licensee and shall be provided for scrutiny any
time to the Insecticide Inspector, Licensing Officer or any other officer authorised by the Central Government
and / or the State Government.

15. Any other condition(s) as specified by the licensing officer.

Signature of the licensing officer

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 Appendix A
REGISTER OF DATE EXPIRED PESTICIDES
[See sub-rule (a) of rule 10A]

Sl. Name of Batch Dat Date Name Stocks Invoic Quan Quantity How was
No. insecticid numbe e of of of receive e tity balance the
e r ma expir manufa d numbe sold (Give balance
Technical nuf y cturer from r (give unit quantity
with min act and and unit details) disposed
purity/ ure the date detail of?
formulatio quantity vide s)
n type and receive which
d receiv
% active (give ed
ingredient unit
details)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

Signature of the dealer with date and seal

Verified with the record and found that the above information is correct.

Place:

Date

Signature of the Insecticide Inspector (seal)

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 Appendix B

REGISTER FOR SALE/DISTRIBUTION OF INSECTICIDES (TECHNICAL AND

FORMULATION) (INCLUDING INSECTICIDES USED IN COMMERCIAL PEST
CONTROL OPERATIONS)

(RECORD TO BE MAINTAIMAINTAINED INSECTICIDE WISE)

[See sub rule (2) of rule 15]

Particulars of the insecticide:

Registration number:

Month and year:

Sl. Date of Name Name Bat Date Date Invoice Quantity (metric tonnes) Bill Rem
No. receipt of the of ch of of details, number arks
of manu supplier nu man expir numbe Previo Rece Sold Balanc (name
the - / mb ufact y r, us ived / e and
insectic factur distribut er ure date address
ide er or, and balanc Distri to
from if any, quantit e, bute whom
whom through y if d sold/distri
receiv whom ( buted)
ed receive metric any date and
d tonnes quantity
) sold/
vide distribute
which d
supply
receive
d

Date:
Signature Company’s seal

Verified with the record and found that the above information is correct.

Signature with date and seal of the Insecticide Inspector

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 Appendix C1
STOCK REGISTER OF TECHNICAL GRADE INSECTICIDE (To be maintained Insecticide wise)
[See sub-rule (3) of rule 15]
(Quantity in metric tonnes)
Dat Openin Quantity Quantity Total Quantity Quantity Total Closin
e g imported manufactured quantity sold utilised for quantity g
balance (2+3+4) formulation (6+7) balanc
e
(1) (2) (3) (4) (5) (6) (7) (8) (9)

Appendix C2

STOCK REGISTER OF FORMULATED INSECTICIDE

(To be maintained insecticide-wise)
[See sub-rule (3) of rule 15]
(Quantity in metric tonnes)
Sl. Openi Technical Total Total Balanc Opening Quantity Total Quantit Closi
No. ng grade techni techni e balance formulat formulat y ng
balan insecticid cal cal of of ed e sold balan
ce e grade grade techni formulatio / d ce
of imported colum used cal ns imported quantity
techni / n for grade (7+8)
cal purchase (2+3) formul insecti
grade d a- -
pestic diverted tions cides
ide (4+5)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

Appendix D1
[See sub rule (4) of rule 15]

MONTHLY RETURN / STATEMENT OF TECHNICAL GRADE INSECTICIDES (MANUFACTURED /

IMPORTED) FOR THE PERIOD……….. TO …………….(2)

Sl.No Name of Batch Date of Details of total Quantity Quantity Quantity sold (Metric
. the number expiry imported/ utilized Tonnes) With Name,
insecticide Manufactured for formulations address and licence
(Metric Tonnes) (Metric Tonnes) number of purchaser
(1) (2) (3) (4) (5) (6) (7)

VERIFICATION

I………………………………… do hereby verify that what is stated above is true to the best of my knowledge
and belief based on information derived from the records. I further declare that I am competent to verify this
statement in my capacity as …………………………………… (Designation). In case the information is found to
be false, I shall be held responsible under relevant provisions of the Act / Rules.

Signature……………………..

Name…………………………

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 Seal…………………………...

Appendix D2
[See sub rule (4) of rule 15]

MONTHLY RETURN/ STATEMENT FOR FORMULATED INSECTICIDES (MANUFACTURED/IMPORTED) FOR

THE PERIOD……….. TO …………….

Sl. Name of the Batch Date of Details of total Quantity of Total formulated /imported
No. Insecticide number expiry technical grade insecticides used Quantity (metric Tonnes)
formulation for formulation (Metric Tonnes)
(1) (2) (3) (4) (5) (6)

VERIFICATION

I………………………………… do hereby verify that what is stated above is true to the best of my knowledge
and belief based on information derived from the records. I further declare that I am competent to verify this
statement in my capacity as …………………………………… (Designation). In case the information is found to
be false, I shall be held responsible under relevant provisions of the Act / Rules.

Signature……………………..

Name…………………………

Seal…………………………...

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 Appendix E
REGISTER OF PERSONS ENGAGED IN CONNECTION WITH INSECTICIDES

RECORD OF PERIODICAL MEDICAL EXAMINATION

FOR THE CALENDAR YEAR 20_______, QUARTER ENDING________, 20____

[See rule 37]

Serial number:

I.GENERAL INFORMATION

Name: Age:

Father's /Husband's name:

Complete address:

Sex: Identification mark:

Date of appointment:

--------------------------- (Please specify the nature of duty of the past and of the
Occupation: present)

Details of use Personnel Protective

Equipments:

(a) Protective clothing/overalls:

(b) Helmet/hood/hat:
(c) Dust-proof goggles:
(d) Rubber gloves impermeable to liquids:
(e) Respiratory device(s):
(f) Boots:

II. MEDICAL EXAMINATION:

PAST HISTORY

Illness Poisoning Allergy Exposure to No. of years/ Remarks, if

pesticides seasons and days of any
(Compound) exposure per year
(1) (2) (3) (4) (5) (6)

FAMILY HISTORY:

Allergy Psychological disorder Hemorrhagic disorders

(1) (2) (3)
Marital Status Nos. of Children –Health status Any other health related
of complaint
children & any birth defect, if any
(4) (5) (6)

PERSONAL HISTORY:

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 Smoking Alcohol Other addiction
(1) (2) (3)
Marital Status Nos. of Children –Health status Any other health related
of complaint
children & any birth defect, if any
(4) (5) (6)
OBSERVATIONS:
Medical Pre- End of 1st After After End of year Remarks
examination employment quarter i.e. 2nd 3rd
examination after 3 quarter after quarter after
6 months 9 months
(1) (2) (3) (4) (5) (6) (7)

1. General Examination :
(a) Height
(b) Weight
(c) Pulse rate
(d) Blood pressure
(e) Respiration: rate , rhythm , type
(f) Anaemia/Pallor
(g) Oedema
(h) Jaundice
(i) Skin condition
(j) Temperature
(k) Fatigability
(l) Sweating
(m) Sleep
(n) Urination

2. Gastro Intestinal
(a) Nausea
(b) Vomiting
(c) Appetite
(d) Taste
(e) Pain in abdomen
(f) Bowel movement
(g) Liver
(h) Spleen

3. Cardio-respiratory

(a) Nasal discharge

(b) Wheeze
(c) Cough
(d) Expectoration
(e) Tightness of chest
(f) Dyspnoea
(g) Palpitation
(h) Heart
(i) Cyanosis
(j) Tachycardia/Bradycardia

4. Neuro-muscular
(a) Headache

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 (b) Dizziness
(c) Irritability
(d) Twitching
(e) Tremors
(f) Convulsions
(g) Paresthesia
(h) Hallucinations
(i)Unconsciousness

(j) Superficial reflexes

(k) Deep reflexes
(l) Coordination

5. Eye
(a) Pupil
(b) Lacrimation
(c) Double vision
(d) Blurred vision

6. Psychological
(a) Temperament
(b) Judgment
(c) Nervousness

7. Kidney

Kidney Condition

8. Investigation

(a) Complete Haemogram : (Hb, TRBC, TLC, DLC, Platelet, Reticulacytes count, ESR)

(b) Liver Function Tests: (Serum Bilirubin, SAP, SGOT, SGPT, Cholesterol, Total Protein and
serum albumin)

(c) Kidney Function Tests: (Blood urea, Serum creatinine)

(d) Blood Sugar, HbA1C
(e) *Serum cholinesterase

(f)** Blood residue estimation (In case of Organochlorine once in a year)

(g) Urine – routine & microscopic

(h) X- ray chest (PA View): Once every year
(i) Ultrasound whole abdomen: Once every year

* Serum cholinesterase level should be measured at six monthly intervals in case of

organophosphorus/carbamatic group of insecticides.

** In organochlorine group of insecticides the blood residue estimation should be done once a year.

General remarks of the doctor in the light of the above examination.

III. DIAGNOSIS

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 IV. ADVICE GIVEN TO

1. The employee
2. The employer:

Signature of the Doctor with date and seal

V. Acknowledgement to be given by
1. The employee
2. The employer:
3. The Licensing Officer:

VI. Action taken by the employer on Doctor’s advice:

VII. Certificate by the Doctor:

Certified that M/s _____________________________________________ have completed the action

as per my/doctor’s advice as given above and consequently the patient has shown improvement/recovered from
the ailment.

Signature of the Doctor with date and seal

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