1 (a) Name, address and
status of the applicant.
(b) Category of the industry - SSI/DGTD/MRTP/FERA/others.
2. Address of the premises where the manufacture will be done.
- The common name and trade name of the insecticides
which the applicant proposes to import or manufacture.
- Whether the application is for import or for manufacture:
(i) in the case of import please state:-
- Name and address of the manufacturer.
- Name and address of the supplier if he is duly authorised by the
manufacturer.
- Is the insecticide registered in the country:
- Of manufacture.
- From which supplies are expected to be made.
- in the case of manufacture please state;
Whether the insecticide is meant for domestic consumption or for
export or for both.
- In the case of formulation, the sources of supply of
technical grade material and its status of registration. Chemical
composition.
- (I) Kind and name of active and other ingredients and percentages
of each.
(ii) Stability in storage (as per details specified by the
Registration committee).
- shelf life claim.
- Toxicity of the products to human beings, wild life,
aquatic animals toxicological data to be enclosed (as per details
specified by the Registration Committee0.
- The plant diseases, insects and other poisonous animals and weeds
against which it is intended to be used. (published/authentic
reports on bioefficacy of the insecticide to be enclosed as per
details specified by the registration committee.
- Instructions for storage and use including first-aid and
precautionary measures which are proposed for labelling.
- (I) ten copies of specifications for product, quality and methods
of analysis for technical/ formulated compound (as applicable ) and
its residues.
(ii) analytical test report for the product quality.
- seven copies of the proposed labels and leaflets
(including all printed or graphic matter which will accompany the
package containing the insecticide0 as per the insecticides rules,
1971.
- Manner of packing.
- Particulars of fee deposited.
--------------------
- substituted by GSR 533(E), dt. 6-8-1993.
- Signature of the applicant With seal
Verification
I &&&&&&. S/o &&&&&&&.
Do hereby solemnly verify that to the best of my knowledge and
belief the information given in the application and the annexures
and statements/ accompanying it is correct and complete.
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 &. A photo/ attested copy of which
is enclosed herewith.
Place&&.. Signature&&&..
Date&&.. with seal
Note: the application form including the verification portion
must be signed in case of an individual, by the individual himself
or a person duly authorised by him; in case of Hindu undivided
family, by the Karta; in case of a partnership firm, by the
managing partner; in case of a company, by a person duly
authorised in that behalf by the Board of Directors, and in any
other case, by a person incharge of or responsible for the conduct
of the business.]
FORM II
GOVERNMENT OF INDIA
MINISTRY OF AGRICULTURE
(Department of Agriculture)
CERTIFICATE OF REGISTRATION OF INSECTICIDES
[Rule 6(4)]
certified that the insecticide &&&.has been
registered in the name of the person/ undertaking whose
particulars are specified below;
1 Name of the Person/ undertaking.
- Address.
- Registration No.
- Name of the insecticide.
(Brand name or trade name or chemical name of the insecticide,
details thereof regarding its composition, etc.)
- Conditions, if any.
New Delhi, the &&19.
Signature&&
Seal of Department
Conditions
1[FORM II-A
GOVERNMENT OF INDIA
MINISTRY OF AGRICULTURE
(Department of Agriculture and Cooperation)
CERTIFICATE OF PROVISIONAL REGISTRATION OF INSECTICIDES
[See rule 6]
- Certified that the insecticide &. Has been registered in the
name of the person / undertaking whose particulars are specified
below provisionally for a period of two years effective from the
date of issue:-
- Name of person / undertaking
- Address
- Registration number
- Name of insecticide
(Brand name or trade name and chemical name or trade name and
chemical name of the insecticide, details of composition).
- Conditions, if any:
(i)
(ii)
(iii)
New Delhi, the &19&
Signature
Seal of Department
FORM II-B
APPEAL UNDER SECTION 10 OF THE INSECTICIDES ACT, 1968,
TO THE CENTRAL GOVERNMENT
[Rule 7]
To,
The Secretary
Ministry of Agriculture,
(Department of Agriculture and Cooperation),
New Delhi,
Appeal No&.. of 19&.
- Name and address of the applicant
- Address of the manufacturing unit:
- Name of the insecticides
- Date of order appealed against
- Date of communication f the order
- Whether the appeal is within limitation period
- Particulars of the fee deposited
- Relief claimed in appeal
- Address to which notice may be sent to the applicant
*Statement of Facts
*Grounds of Appeal
Signature (appellant)
*(Please give each ground in a separate paragraph and number it).
Signature (appellant)
VERIFICATION
I&&.S/o &. The appellant, do hereby verify that what is
stated above is true to the best of my knowledge and belief:
Date:
Place:
Signature (Appellant).
- The appeal must be preferred in duplicate and must be accompanied
by a copy of the order appealed against.
- The form of appeal, grounds of appeal and the form of
verification must be signed incase of an individual by the
individual himself or a person duly authorised by him; in case of
Hindu Undivided family by the karta; in case of partnership company,
by the managing partner; in the case of company, by a person duly
authorised by the Board of Directors and in any other case, by the
person incharge or responsible for the conduct of the business.]
1[FORM III
APPLICATION FOR THE GRANT OF LICENCE TO MANUFACTURE INSECTICIDES
[Rule 9]
- Name, address and status of the applicant:
- Address of the premises where the manufacturing activity will be
done:
- Name of the insecticides with their registration number and date
for which manufacturing licence is applied for (enclose copies of
certificate of registrations duly signed by the applicant).
- Whether any registration is provisional, if so give particulars
Name of insecticides Registration No. Date
1.
2.
3.
5. Details of full time expert staff connected Name
Qualification Experience
with the manufacture and testing of the 1.
Insecticides in the above unit: 2.
3.
- Whether all the facilities required under
- Chapter VIII of the rules have been provided, Give full details
in a separate sheet.
- Particulars of the fee deposited:
Signature of the applicant
Verification
I&. S/o&&.. do hereby solemnly verify that to the best of
my knowledge and belief the information given in the application and
the annexures and statements accompanying it, is correct and complete.
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 & a photo/ attested copy of which is enclosed herewith.
Date:
Place:
Signature with seal.]
FORM IV
APPLICATION FOR RENEWAL OF LICENCE
TO MANUFACTURE INSECTICIDES
[RULE 9(1)]
- I / We&& of &. Hereby apply for the renewal of the
licence to manufacture insecticides on the premises situated at&
(Licence No. and date to be given).
- The other details regarding the manufacture of the insecticide
continue to remain the same.
- [1] particulars of the fee deposited.]
- the licence is enclosed herewith.
Date&.
Signature&&
2[Verification
I && S/o&&.. do hereby solemnly verify that what is
stated above is true and correct to the best of my knowledge and
belief.
-------------
- substituted by GSR 533(E), dt. 6.8.1993.
- inserted by GSR 533(E), dt. 6.8.1993
----------
I further declare that I am making this application in my capacity as &..
designation) and that I am competent to make this application andverify
it, by virtue of &. A photo/ attested copy of which is enclosed.
Date
Place
Signature with seal
*If there is any change in the details of manufacture or conditions
of licence subject to which the licence is required to be renewed, the
same may be indicated here.
FORM V
[Rule 9(3)]
- Number of licence and date of issue&&.
- &.. of &&.is hereby granted a licence to manufacture
the following isecticides on the premises situated at&.. under
the direction and supervision of the following expert staff.
- Expert staff (name)&&
- Name of insecticides&.
- The licence authorises the sale by way of wholesale
dealing by the licensee and storage for sale by the licensee of
insecticides manufactured under the licence.
1[PROVIDED such sales are made from or storage is done in the
factory premises.]
- The licence shall be in force for a period of &.years
from the date of issue.
- The licence is subject to the conditions stated below and to such
conditions as may be specified in the rules for the time being in
force under the Insecticides Act, 1968.
Date:
Signature&..
Designation
Seal of the Licensing Officer
Conditions
- This licence and any certificate of renewal shall be kept on the
approved premises and shall be produced for inspection at the
request of an Insecticides inspector appointed under the
Insecticides act 1968 or any other officer or authority authorised
by the licensing officer.
- Any `change in the expert staff named in licence shall forthwith
be reported to the licensing officer.
- If the licensee wants to undertake during the currency of the
licence to manufacture for sale of sale of additional insecticides,
he should apply to the licensing officer for the necessary
endorsement in the licence on payment of fee of rupees&& for
every category of insecticides.
- [1]. An application for the renewal of a licence shall be made as
laid down in rul 11.]
- [2] the licensee shall comply with the provisions of the
insecticides act 1968, and the rules made thereunder for the time
being in force.]
- [3] The licensee shall obtain ISI mark certificate from Bureau of
Indian Standard within three months of the commencement of the
manufacture.
- No insecticides shall be sold or distributed without ISI Mark
Certification.]
FORM VI
APPLICATION FOR THE GRANT OF LICENCE TO SELL, OR EXHIBIT FOR SALE
OR DISTRIBUTE INSECTICIDES
[Rule 10(1)]
To,
The Licensing Authority,
State of&&.
- Full name and address of the applicant
- Is the applicant a newcomer? 9say "yes" or "no")
- If yes, the names of the principals, if any, whom he represents.
(4)[***].
- I enclose a certificate from the principals whom I represent or
whom I intend to represent and the source/ sources from which
insecticides will be obtained.
- 4[***].
- Situation of the dealr's premises where the insecticide will be
(a) stored; and (b) sold.
- The names of insecticides in which the applicant desires to carry
on business.
- Full particulars of licences issued in his name by other state
Government, if any, in their area.
- I have deposited the licence fee.
-
Treasury Challan No&&..
Sub-Treasury&&..
- Declaration:
- I / We declare that the information given above is true to my /
our knowledge and belief, and no part thereof is false.
- 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 a applicant.
Remarks by the licensing authority.
-----------
- substituted by GSR 474(E), dt. 24-07-1976.
- Inserted by GSR 474(E) ,dt 24-7-1976
- Conditions 6 and 7 inserted by insecticides (Iind Amendment) rule
1999, dt. 2005. 1999.
- Omitted by GSR 533(E) , dt. 6-8-1993.
1[FROM VI-A
[Rule 10(3A)]
APPLICATION FOR THE GRANT OF LICENCE TO STOCK AND USE RESTRICTED
INSECTICIDES(S) FOR COMMERCIAL PEST CONTROL OPERATIONS(S)
To,
The Licencing Authority,
&&&&&&&&&&
-
- Full name of the applicant (Block letters)
- Address:
-
- Registered Office
(ii) Zonal Office
(iii) Premises for which application is made
-
- Is the applicant already in business or newcomer
- Qualifications of responsible technical person
- (i)Educational Qualification (ii) training in pest control
operations
(iii) Experience in using restricted insecticide (s) (attach
proof in respect of claims)
- If in the trade, give full particulars of the names of
restricted insecticides(s) handles and categories fo operations
undertaken, the period and the place(s) at which the trade was
carried on.
- Quantity(s) of each restricted insecticide in possession on
the date of application (Give details of place (s) where it is
stored).
- Details of persons engaged or proposed to be engaged (Attach
separate sheet, duly authenticated)
- Details of safety applications available along with antidotes
and all other facilities required under chapter will be stored
for use.
- Situations of the branch offices and depots where the
restricted insecticide (s) will be stored for use.
- Name (s) of restricted insecticides (s) which the applicant
desires to use.
- Category (s) applied for.
- Particulars of the fee(s) deposited.
- Whether technical expertise approved by the plant protection
adviser to the Government of India for undertaking pest control
operations Attach Proof).
- Whether permission obtained from Plant Protection Adviser to
the Government India for undertaking fumigation (attach Proof &
validity).
Signature of the applicant
Verification
I &&&& S/o&&& do hereby 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&.. and that I am competent to make this application and
verify it, by virtue of &.. a photo or attested copy of which is
enclosed herewith.
Date
Place
Signature with seal
FROM VI B
[Rule 10(3A)]
Application for renewal of licence to stock and use
of restricted insecticides for commercial pest control
operations(s).
To,
The Licensing Authority,
State&&&&&&&..
I / We hereby apply for renewal of the licence to
stock and use of restricted insecticides for categories; I, II and III
under by the Licensing Authority and allotted licence desired to be
renewed was granted by the licensing authority and allotted licence No.
&& on the day of &..29&.
- State of Change, if any in:-
- category of operation
- expert staff
- restricted insecticides used
- premises of stocking
- address including of branch offices
- whether any new branch / unit has been opened after grant or
renewal of licence
- any other change.
- Particulars of fee deposited
- Give latest details of persons engaged (attach separate sheet
duly authenticated)
Signature of the applicant
Verification
I &&&S/o &&.. do hereby solemnly verify that to
the best of my knowledge and belief the information given in the
application and the annexures and statements accompanying it, it
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 has already been submitted.
Signature with seal
Date
Place
FORM VI-C
[Rule 10(3A)]
licence to stock and use restricted insecticide(s)
for commercial pest control operations
1&&&&& is hereby licenced to stock restricted
insecticides viz&&. On the premises situated at&& and
carry out commercial pest control operations subject to the conditions
specified below and to the provisions of the insecticides act, 1968
and the rules thereunder.
- Licence shall be in force from &&. To &&&..
- Conditions , if any
(i)
(ii)
(iii)
Date:
Licence No&&..
Licensing Authority seal]
1[FORM VI-D
PRINCIPAL CERTIFICATE
[Rule 10(4-A)(I)]
Name and address of the manufacturer Principal certificate No.
Date
---------------------
- inserted by insecticides (IInd amendment ) rules, 1999.dt.
20.5.1999.
We have insecticide manufacturing licences for our factories as
given below:-
| Sl. No. |
Name & Address of the
Manufacturing premises |
Licence No. |
Date |
Valid upto |
Name & address of the
Licensing Authority |
| 1 |
2 |
3 |
4 |
5 |
6 |
| |
|
|
|
|
|
This is to certify that M/s&&& have applied for
grant of licence (Form VI)/ renewal of Licence (Form VII) to sell, stock
or exhibit for sale or distribution of insecticides as per sub-rule (1)
of rule 10 of the insecticides rules, 1971. We authorise them to sell,
stock or exhibit for sale or distribution of the following insecticides
in wholesale/ Retail in&& Taluka/District/State.
| Sl. No. |
Common Name of Insecticide |
Trade mark of the insecticide |
Registration No. |
Date |
| |
|
|
|
|
As per sr. no. 5 of the Form VI the above dealer will obtain
our insecticides from the following source /sources
| Sl. No. |
Name of Source(s) |
Detailed address of the
source(s) |
Licence No. & Date |
Licence valid upto |
Detailed address of the
premises where source(s) are stocking insecticides |
| 1 |
2 |
3 |
4 |
5 |
6 |
| |
|
|
|
|
|
The dealer to whom this principal certificate has been issued
will purchase our insecticides from the source / sources stated above
and if he purchases our insecticides from sources other than those
stated above then it would be a contravention of the insecticides act,
1968 and rules made thereunder.
This principal certificate is valid upto&..
Date
Place:
Company's seal
Signature (Authorised Signatory)
Designation
Detailed address
I shall obtain the insecticides shown in the principal certificate
from the source / sources which are stated above. I am aware that if,
I obtain these insecticides from source/ sources other than those
stated above, this would be contravention of the insecticides act,
1968 and rules made thereunder.
Date
Place
Dealer's seal
Signature
Name:
Designation
Address of the Dealer
Dealers Licence No and Date
(if issued for renewal of licence)
copy submitted to the concerned licensing Authority
[F. No. 19-3/96-PP.I]
P.D. Sudhakar, jt. Secy.
Note:- the principal rules were published in the Gazettee of India,
vide number GSR 1650, dated 11th October, 1971 and
subsequently amended vide GSR 533(E) dated 6-8-1993, and GSR 379(E)
dated 2-798.]
FORM VII
APPLICATION FOR RENEWAL OF THE LICENCE TO SELL, STOCK OR EXHIBIT
FOR SALE OR DISTRIBUTE INSECTICIDES
[Rule 10(1)]
To
The Licensing Authority
State of &&
I / We hereby apply for renewal of the licence to sell, stock or
exhibit for sale or distribute insecticides under the name and style
of&& the licence desired to be renewed was granted by the
licensing authority for the state of &.. and allotted licence No&&
on the day of &.19&&..
The situation of the applicant's premises where the insecticides are/
will be-
- stored and (b) sold
(i) I /We hereby declare that the situation of my / our premises
where the insecticides are stored, and (b) sold, as stated below:
-
- (b)
(ii) the insecticides in which i/We am/ are carrying on business
and the name of the principals whom I / we represent are as stated
below:
full name and address of the applicant in block letters&&&&..
date
place
signature of applicant(s).
FORM VIII
LICENCE TO SELL, STOCK OR EXHIBIT FOR SALE OR DISTRIBUTION OF
INSECTICIDES
[Rule 10(4)]
1&&&&.. is hereby licensed to sell, stock or exhibit
for sale or distribute by retail, insecticide&.. on the premises
situated at&.. subject to the conditions specified below and to
the provisions of the insecticides act, 1968 and the rules thereunder.
- licence shall be in force from&&& to&&&&..
1[3***]
date
Licence No&&&
Licensing Authority
Seal
Conditions:
- the licence shall be displayed in a prominent place in a part of
the premises open to the public.
- The licence shall comply with the provisions of the insecticides
act, 1968, and the rules made thereunder for the time being in
force.
- [1] no insecticides shall be sold or distributed except in
packages which are or may be approved by the Indian standards
Institution from time to time.
3-A. if the licensee wants to sell, stock or exhibit for sale or
distribute any additional insecticides during the currency of the
licence he may be apply to the licensing officer for issuance of
separate licences for each insecticide on payment of the prescribed
fee.]
3[4. An application for the renewal of a licence shall be made as laid
down in rule 11.]
"Triplicate"
FORM IX
REPORT OF INSECTICIDE ANALYST
[RULE 24(3)]
- Name of the insecticide inspector from whom received&
- Serial No. and date of insecticide inspector's memorandum&..
- Number of sample&..
- Date of receipt&..
- Name of the insecticide purporting to be contained in the sample&..
- Conditon of the sales on the package&.
- Result of test or an analysis with protocols of test applied&&&.
- Date&&&.
Insecticide analyst.
----------------
- Omitted by GSR 533(E), dt. 6.8.1993.
- Substituted by GSR 5333(E),dt. 6-8-1993
- Inserted by GSR 474(E), dt. 24-7-1975.
FORM X
ORDER UNDER SECTION 21 (D) OF THE INSECTICIDES ACT, 1968,
REQUIRING A PERSON NOT TO DISPOSE OF ANY STOCK IN HIS POSSESSION
[Rule 30]
whereas I have reason to believe that the stock of &&& in
your possession, detailed below, is being distributed, sold or used in
contravention of the provisions of section&& of the
insecticides act, 1968 or && of the insecticides rules, 1971.
I hereby require you under section 21(1) (d) of the said act, to stop
the distribution, sale or use of the said stock for a period of&&
days from this date.
Date&..
Details of stock of insecticides formulation.
1.
2
3
4
5
6
insecticide inspector
seal.
Date
FORM XI
FROM OF RECEIPT FOR THE SEIZED INSECTICIDES
[RULE 32]
Receipt for stock of insecticide seized under section 21(1)
(d) of the insecticides act, 1968.
The stock of the insecticide detailed below has this day been seized
by me under the provisions of sections 21(d) of the insecticides act,
1968 from the premises of &.. situated at&&..
Details of the insecticide seized are;
(a)
(b)
(c)
(d)
insecticide Inspector
Date
Official Stamp.
FORM XII
INTIMATION TO ERSON / LICENSEE FROM
WHOM SAMPLE IS TAKEN
See rule 33]
To ,
&&&&&&&&.
&&&&&&&&..
&&&&&&&&.
I have this day taken from the premises of &.. situated at&&
samples of the insecticide specified below for the purposes of test or
analysis.
Date
Insecticide inspector.
Details of sample taken.
Date
Insecticide Inspector.
1[FORM XIII
REGISTER OF SALES MADE TO BULK CONSUMERS, INSECTICIDES WISE
[Rule 15]
|
Sl. No.
|
Date
|
Name of the insecticides with its strength
and brand name
|
Name of the manufacturer
|
Batch no.
|
Date of expiry
|
Name of the purchaser with full address
|
*licence no. of purchaser
|
Qty. sold size no. of qty. of packs the sold
pack
|
Remarks
|
| |
|
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
|
- in case of bulk consumer give number and ate of the order.
------------------
- substituted by GSR 533(E), dt. 6-8-1993.
FORM XIV
MONTHLY RETURN OF SALES OF INSECTICIDES MADE TO THE BULK CONSUMERS
OF THE STATE OF &. FOR THE PERIOD FROM&&.. TO&. 19&..
[RULE 15]
| Sl. No. |
Name of the insecticides with
its brand name strength and type of formu- lation |
Manufactured by |
Batch no. |
Date of expiry |
Name of the purchaser with
full address |
*licence no. of purchaser |
Size of pack |
No. of packs sold |
Qty. |
| |
|
|
|
|
|
|
|
|
|
*in case of bulk consumer give number and date of the order.
Signature
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 and
verify this statement in my capacity as&. (designation)
Signature&&&
Name&&&&.
Seal&&&&..
FORM XV
STOCK REGISTER OF TECHNICAL GRADE INSECTICIDE&.
[RULE 15]
|
DATE
|
Opening balance
|
Qty. imported
|
Quantity manufactured
|
Total quantity (2+3+4)
|
Qty. sold
|
Qty. utilised for formulation
|
Total quantity (6+7)
|
Closing balance
|
| |
|
|
|
|
|
|
|
|
(quantity in metric ton)
&&&&&&&.
FORM XVI
STOCK REGISTER OF FORMULATED INSECTICIDE&&&&&&..
[RULE 15]
"triplicate'
FORM XVII
(Rule 24)
Report of insecticides analyst &&&&&.. sl.
No&&&&&&&&&.
- Name of the Insecticides inspector, from whom samples have been
received.
- Serial No. and date of Insecticides inspector's Memorandum.
- Number of the sample.
- Date of receipt.
- Name of the insecticides purporting to be continued in the
sample.
- Condition of the seals on the package: state whether:-
- (i) the sample was properly sealed and fastened (ii) the seal was
intact and unbroken:
(iii) the seal fixed on the container and the outer cover of the
sample tallied with the specimen impression of the seal separately
sent by the insecticides inspector, and
(iv) the sample was in condition fit for analysis.
- Date of the test or analysis.
- Result of test or analysis with protocols of test applied.
Verification
I certify that I have analysed / caused to be analysed the
aforementioned sample, and declare the result of analysis to be as
above.
Signed this&& day of &&. 19&..
(signature with seal)
Insecticide Analyst
FORM XVIII
ORDER UNDER SECTION 21(1) (d) OF INSECTICIDES ACT, 1968 REQUIRING
A PERSON NOT TO DISPOSE OF ANY STOCK IN HIS OSSESSION
(Rule 30)
whereas I reason to believe that the stock of &. In your
possession detailed below, is being distributed, sold or used in
contravention of the provisions of section&. Of insecticides act,
1968, or&. Of the insecticides rules, 1971.
I hereby require you under section 21(1)(d) of the said act to stop
the districution, sales or use of the said stock for a period of &.
Days from this date&.
Details of stock of insecticides/formulation..,
Date
1.
2.
Date
Insecticides Inspector
Seal
FORM XIX
FORM OF RECEIPT FOR THE SEIZED INSECTICIDES
[Rule 32]
Receipt for stock of insecticides seized under section 21((1)(d) of
the Insecticides Act, 1968.
The stock of the insecticides detailed below has this day been seized
by me under the provisions of section 21(1)(d) of the insecticides
act, 1968 from the premises of&. Situated at.
Details of the insecticides seized are:
(a)
(b)
Date:
Insecticides Inspector
(Official Stamp)
FORM XX
INTIMATION TO PERSON / LICENSEE FROM WHOM SAMPLE IS
TAKEN
[Rule 33]
To,
&&&&&&&&&&.
&&&&&&&&&&.
I have this day taken from the premises of &situated at &samples
of the insecticides specified below for the purposes of test or
analysis.
Date :
Insecticides inspector
Details of samples taken
Date:
Insecticides Inspector
FORM XXI
MEMORANDUM TO GOVERNMENT ANALYST
[Rule 34]
From
&&&&&&&&&..
To,
The Government Analyst
&&&&&&&&&&
The portion of samples / container described below is sent herewith
for test or analysis under rule 34 of the Insecticides Rules, 1971.
The portion of samples /container has been marked by me with the
following mark:
Details of portion of sample or container with name of insecticide
which it purports to contain.
Date :
Insecticides Inspector
(Seal)
FORM XXII
REGISTER OF PERSONS ENGAGED IN CONNECTION WITH
INSECTICIDES AND THEIR PERIODICAL MEDICAL EXAMINATION FOR THE YEAR 19&&..
[Rule 37]
Serial No&&&.
Name&&&Age&&.
Father's/Husband's Name&&&&&Full address&&&
Sex&&&Identification mark&&
Date of appointment&&&&&..Occupation: (Please
specify the nature of duty)
1. Past 2. Present
Past History
| Illness |
Poisoning |
Allergy |
Exposure to pesticides
(Compound) |
No, of Years/reason |
Remarks, if any |
| 1 |
2 |
3 |
4 |
5 |
6 |
| |
|
|
|
|
|
Family History
| Allergy |
Psychological disorders |
Haemorrhagic disorders |
| 1 |
2 |
3 |
| |
|
|
Personal History
| Smoking |
Alcohol |
Other addiction |
| 1 |
2 |
3 |
| |
|
|
Observations
| Medical Examination |
Pre- employment examination |
End of 1st
quarter i.e. after 3 months |
After 2nd quarter
after 6 months |
After 3rd quarter
after 9 months |
End of year |
Remarks |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
| |
|
|
|
|
|
|
- General Examination
General body limit
Weight
Piles
Blood pressure
Respiration
Anaemia
Dadema
Jaundice
Skin condition
Temperature
Fatigability
Sweating
Sleep
Urination
II. Gastro Intestinal
Nausea
Vomiting
Appetite
Taste
Pain in abdomen
Bowel movement
Liver
Spleen
III. Cardio-respiratory
Nasal discharge
Wheeze
Cough
Expectoration
Tightness of chest
Dyspnoea
Palpitaion
Heart
Cyanosis
Tachycardia
IV. Neuro-muscular
Headache
Dizziness
Irritability
Pulse
Twitchings
Tremors
Convulsion
Paranesthesia
Hallucination
Unconsciousness
Deep reflexes
Superficial reflexes
Coordination
V. Eye
Pupil
Lachrymation
Double vision
Clumped vision
VI. Psychological
Temperament
Nervousness
VII. Kidney
Kidney condition
VIII Investigation
Blood hb%
Blood D.C.
*serum Cholinesterage
Serum Billirubin
Urine routine examination
Urine microscopic
x-ray of chest-
- serum cholinesterage level should be measured in monthly
intervals in case of organophosphorus/ carbamatic group of
insecticides. General remarks of the doctor in the light of the
above examination;
advice given to;
-
- Doctor
- Employees:
- Employer / Manufacturer:
- Licensing officer at the time of inspection.
N.B. - in organochlorine group of insecticides the blood residue
estimation should be done once a year.]
