Personal information requested on this form is collected under the authority of the Pesticides Act, R.S.O., 1990, Ontario Regulation 63/09. It is used to evaluate applications for permits to use restricted pesticides according to the requirements of the Pesticides Act.
Questions regarding completion and submission of this application should be directed to the Pesticides Specialist in the local Regional Office of the Ministry of the Environment. Regional Office contact information is available on the Ministry of the Environment website at. http://www.ene.gov.on.ca/en/contact/index.php.
Information contained in this application form is not considered confidential and will be made available to the public upon request. Information submitted as supporting information maybe claimed as confidential but will be subject to the Freedom of Information and Protection of Privacy Act (FOIPPA) and the Environmental Bill of Rights (EBR). If you do not claim confidentiality at the time of submitting the information, the Ministry of the Environment may make the information available to the public without further notice to you. If you are identifying confidential material, please indicate why you believe the information is confidential.
For Ministry Use Only Client Number
Name of Applicant Exterminator Licence Number Name of Pest Control Company
Unit Number Street Number Street Name PO Box City/Town Municipality Province Postal Code
Name Licence Number
Name of assistant Licence Number Duties
Name of Premises Type of Facility
Zone Easting Northing
Description and size of premises
Date (dd/mm/yyyy) Time A.M. P.M.
Name of Pesticide Pest to be controlled Active ingredient(s) PCP Number Rate and amount to be used
Signature of applicant Date (dd/mm/yyyy)