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Active Constituent Number:

1

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Active Constituent Name:

Product Number:

Full Product Name:

1

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Please list the constituents as stated on the label or list the full formulation, if required. Please include the concentration and units of the constituents. For example, 1g/L Pyrethrins, 10g/L Piperonyl butoxide.

Product Formulation:

GMP Licence Code:

Licensee Name:

1

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Permit Number (PERxxx):

Permit Description: