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. 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

Applicant Information

Name of Applicant

Applicant Address

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

Telephone Number

Name of Company

Company Address

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

Business Telephone Number

Has a permit been issued previously?

No Yes

Last Permit Number
Amount of pesticide left over from last treatment?

Are you a certified farmer under the Pesticides Act?

No Yes, complete below
Grower Pesticide Safety Certificate Number
Expiry Date (dd/mm/yyyy)

Are you a licensed land exterminator under the Pesticides Act?

No Yes, complete below
Land Exterminator Licence Number
Expiry Date (dd/mm/yyyy)

Operator Name
Operator Licence Number

Telephone Number

Pesticide and Application Site Information

Name of pesticide(s)

Location and Address of Premises to be treated

(IF NO ADDRESS IS AVAILABLE ATTACH MAPS WITH SUPPORT DOCUMENTATION)

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

Telephone Number

PCP Number
Active Ingredient (s)
Lot Number
Concession Number
Township
Crop or site to be treated
Size of treatment area
County, District or Regional Municipality
Pest(s) to be controlled
Number of Treatments

Requested date of pesticide treatment

From (dd/mm/yyyy) To (dd/mm/yyyy)

Rate of Application
Total quantity of pesticide to be used
Type of equipment for applying pesticide
Signature

Date (dd/mm/yyyy)