Government of Ontario: Ministry of the Environment

Application for a Permit to Use a Pesticide in a Land Extermination

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.

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.

Applicant Information

Applicant Address

Telephone Number

Company Address

Business Telephone Number
Has a permit been issued previously?


Are you a certified farmer under the Pesticides Act?


Are you a licensed land exterminator under the Pesticides Act?


Telephone Number


Pesticide and Application Site Information

Location and Address of Premises to be treated


Telephone Number

Requested date of pesticide treatment