PDF Application for Registration of Pesticides

[Pages:2]STATE OF NEVADA DEPARTMENT OF AGRICULTURE

405 South 21st Street Sparks, Nevada 89431

APPLICATION FOR REGISTRATION OF PESTICIDES

Application is hereby made for the registration of the following number (

) of pesticide products for a period beginning

with the actual date of registration and continuing until December 31, ______. There is submitted as part of this application, a copy of

the label for each product. (See instructions.)

Remittance payable to Nevada Division of Agriculture in the amount of $__________________ is enclosed herewith to cover annual inspection fees for the following brands. ($125 for each product)

BRANDS (Name of product must agree exactly with name on label)

EPA REGISTRATION NO.

(For additional products attach an 8?"x11" sheet.)

I hereby certify that the information appearing on the attached data sheets is true and correct in every respect; that each and every package of the above-named material will be labeled as described (and in addition that net weight and manufacturer's name and address will be shown); that the attached declarations are the guarantees of the applicant as to the chemical composition of the material above-named for and on behalf of:

Name and address of label:

Submitted by:

Firm Street and No. City, State Date Applicant Federal EIN

DAPD 30 (Rev 11/13)

Firm Attn: Telephone # Mail Address City, State, Zip Email address

Fax No

INSTRUCTIONS

APPLICATION FOR REGISTRATION: Submit together with a label for each product being registered. If registration is applied for on behalf of several companies, separate forms should be submitted for each claim.

PLEASE submit only ONE application form for all products listed and submit only ONE label for each product being registered.

LABELING. Each container must bear a label showing the following information:

1. Name and address of the manufacturer, registrant, or person for whom manufactured. 2. Name, brand or trademark under which the product is sold. 3. Net weight or measure of the contents. 4. A statement showing percentage of each active ingredient.

If the pesticide contains arsenic in any form, the ingredient statement must also include a statement of total and water-soluble arsenic, each calculated as elemental arsenic. 5. Adequate warning or caution statement. 6. Any pesticide containing arsenic or any substance or substances highly toxic to man, shall bear in addition the following: (a) The skull and crossbones. (b) The word "Poison" in red on a background of distinctly contrasting color. (c) An antidote statement. 7. Adequate directions for use.

REGISTRATION FEE: $125.00 per product.

PLEASE NOTE A registrant who offers a pesticide for sale before registration of the pesticide shall pay an amount equal to twice the registration fee for registration of the pesticide.

(NRS 586.270.3)

MAKE CHECKS PAYABLE TO: Nevada Department of Agriculture

ADDRESS CORRESPONDENCE TO: Chief Chemist

Nevada Department of Agriculture 405 South 21st Street

Sparks, Nevada 89431

Telephone (775) 353-3600

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