Government of Ontario: Ministry of the Environment

Application for a Permit to Perform an Extermination from an Airborne Machine

Please print clearly

For Ministry Use Only
Client Number

Applicant’s Name
Company Name
Exterminator’s Name
Operator for Whom Extermination will be Done

Applicant

Address

Unit Number
Street Number
Street Name
PO Box
City/Town
Province
Postal Code

Telephone Number

Land Exterminator

Licence Number

Telephone Number

Operator

Licence Number

Telephone Number

Ministry Use Only

No
Reg. Consent

4. Location to be Treated

Lot
Concession
Township
County/District/Municipality

5. Crop
6. Name of Pest
7. Name of Pesticide
8. Number Hectares
9. Rate – kg. / Hectare
10. Treatment Period

11. Property Owner or Contact Person

Name
Address
Postal Code

Telephone Number

Amendment

Ministry Use Only

No
Reg. Consent

4. Location to be Treated

Lot
Concession
Township
County/District/Municipality

5. Crop
6. Name of Pest
7. Name of Pesticide
8. Number Hectares
9. Rate – kg. / Hectare
10. Treatment Period

11. Property Owner or Contact Person

Name
Address
Postal Code

Telephone Number

Amendment

Ministry Use Only

No
Reg. Consent

4. Location to be Treated

Lot
Concession
Township
County/District/Municipality

5. Crop
6. Name of Pest
7. Name of Pesticide
8. Number Hectares
9. Rate – kg. / Hectare
10. Treatment Period

11. Property Owner or Contact Person

Name
Address
Postal Code

Telephone Number

Amendment

Ministry Use Only

No
Reg. Consent

4. Location to be Treated

Lot
Concession
Township
County/District/Municipality

5. Crop
6. Name of Pest
7. Name of Pesticide
8. Number Hectares
9. Rate – kg. / Hectare
10. Treatment Period

11. Property Owner or Contact Person

Name
Address
Postal Code

Telephone Number

Amendment

Applicant

Signature

Date (yyyy/mm/dd)

Permission is hereby granted under the Pesticides Act and Regulations to perform an extermination(s) from an Airborne machine in accordance with the conditions and amendments detailed above

Director

Signature

Date (yyyy/mm/dd)