FORM OF APPLICATION FOR POISON LICENSE

(Vide Rules 3 of Delhi Poisons Rules)

1. Name of the applicant:

2. Father’s name:

3, Permanent address:

4. Permanent address:
(in case where license is
required in the name
of firm/ institution).

5. Name of the firm/institution

7. Whether participants or Limited

Company (in case of firm)
(b) If partnership, particulars:
Sl No. Name Father’s Name Present Address/
Permanent Address

8 a) If institution, whether : Yes/No

b) If yes Registration No and
date of registration :

9 a) If firm/comp, whether register : Yes/No

and date of Registration

PART-B (Details of licensee required)

10. Reasons for which license is required :

Sl No. Name of the poison Qty at a time Qty. per year

11. Premise at which poison (s) :

are to be stored.

12. Purpose for which poison (s :

are required.

(Other relevant particulars):

13. a) whether any poison license is : Yes/No
presently held:
b) if yes, details of the licensee held :
Sl No. Name of the poison Qty at a time Qty. per year License No & date

14. a) whether any poison license was : Yes/No

applied for previously.
 b) If yes, whether granted or not : Yes/No
c) If not, granted reason thereof:

15. a) whether applicant/firm/institution is registered

with Sales Tax Deptt.

b) Under Local Tax Act : Yes/No

c) Under Central Sales Tax Act : Yes/No

If yes, registration No.__________________________Date of Regd._____________

16. Whether applicant/firm/institution

is registered under shop & Estt. Act. Yes/No
b) If yes, registration No.__________________(dt of regd.__________________

Signature of applicant/owner/propwriter
Date