Application For Registration And/or Reregistration (Renewal) Of Pesticides Form printable pdf download

Application For Registration And/or Reregistration (Renewal) Of Pesticides Form

MISSISSIPPI DEPARTMENT OF AGRICULTURE AND COMMERCE

BUREAU OF PLANT INDUSTRY

Phone (662) 325-3390

I. APPLICATION FOR REGISTRATION AND/OR REREGISTRATION (RENEWAL) OF

PESTICIDES

Mississippi Pesticide Law of 1975: Sections 69-23-1 through 69-23-29, Mississippi Code 1972

Complete this application for registration of the pesticides named below and return to the Bureau of Plant Industry, P.O. Box 5207,

Mississippi State, MS 39762. See the pesticide registration instructions for completing this application.

TYPE OR LEGIBLY PRINT ALL INFORMATION

Enclose payment to the Bureau of Plant Industry for $__________ ($200 per brand) to cover annual registration fees for __________

pesticide brands. Make check or money order payable to MDAC.

REGISTRANT:

SEND CORRESPONDENCE TO:

Company Name:_______________________________ Firm:______________________________________

Contact Person:________________________________ Contact Person: _____________________________

Address: _____________________________________ Address:___________________________________

City, State, and Zip:_____________________________ City, State, and Zip:__________________________

E-Mail Address_________________________________ E-Mail Address_____________________________

Phone No:_________________Fax:________________ Phone No._________________Fax:_____________

Date:_____________________

II. COMPLETE THIS SECTION “ONLY” IF YOU HAVE PRODUCTS PRODUCED IN MISSISSIPPI.

I, hereby, apply for rebate of pesticide registration fees in the amount of $__________($100.00 per brand) for _________ number of

pesticide product(s)

I am submitting a notarized statement declaring truthfully that said products have been/shall be produced in Mississippi during

the calendar year for which registration is requested. To meet this requirement, I the applicant, shall allow an inspection by the

Bureau of Plant Industry during normal business hours of any and all establishments.

____________________________________

______________________________

_________________

(SIGNATURE)

(TITLE)

(DATE)

THIS SECTION FOR BUREAU OF PLANT INDUSTRY USE ONLY

This stamped “approved” form certifies the brands/products so named on the attached document have been duly registered,

registration fees have been paid, and the sale and use of each product in Mississippi is authorized through

December 31, 2007.

APPROVED:

RECEIVED:

Check No.

Amount

Page 1

SUBMIT IN DUPLICATE

Application For Registration And/or Reregistration (Renewal) Of Pesticides Form