Pesticide Business/Agency Registration Form
Pesticide Business/Agency Registration Form Business Contact Information: • Name of Business/Agency: _____________________________________________________ • Contact Person: ___________________________________________________________ Phone Number: __________________________________________________________________ Email Address: __________________________________________________________________ • Contact Person: ___________________________________________________________ Phone Number: __________________________________________________________________ Email Address: __________________________________________________________________ • Business/Agency Physical Address: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ • Business/Agency Mailing Address: _ _______________________________________________________________________ _______________________________________________________________________ Type Of Pest Control Activitie …
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Pesticide Business/Agency Registration Form Business Contact Information: • Name of Business/Agency: _____________________________________________________ • Contact Person: ___________________________________________________________ Phone Number: __________________________________________________________________ Email Address: __________________________________________________________________ • Contact Person: ___________________________________________________________ Phone Number: __________________________________________________________________ Email Address: __________________________________________________________________ • Business/Agency Physical Address: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ • Business/Agency Mailing Address: _ _______________________________________________________________________ _______________________________________________________________________ Type Of Pest Control Activities: Agricultural Pest Control Rights of Way Pest Control: Crop Pest Control Industrial, Institutional, & Structural Pest Control Livestock Pest Control Public Health Pest Control Ornamental and Turf Pest Control Regulatory Pest Control Aquatic Pest Control: Demonstration & Research Pest Control Antifouling Paints: Non-Soil Fumigation Swimming Pool Treatments: INSTRUCTIONS: Please complete all of the requested information above. You must identify at least one contact person who is a certified pesticide applicator and check the boxes that apply to all pesticide activities conducted by your business for which that person is certified. • Pursuant to Section 803-38 of the VI Pesticide Rules and Regulations, a pesticide business registration fee of $500.00 must be paid every three years. An additional fee of $50 will apply if the applications is submitted less than 30 calendar days prior to the expiration of the business registration or any time thereafter. • A SEPARATE REGISTRATION IS REQUIRED EACH BUSINESS LOCATION WITHIN THE TERRITORY. • The registration will expire three years after the date upon which the registration was issued. • Pesticide Businesses/Agencies must also comply with the reporting requirements under Section 803-81. • THIS FORM MUST BE ACCOMPANIED BY A COPY OF THE BUSINESS CERTIFICATE OF INSURANCE. Responsible Pesticide Applicator License Number: ______________________________ Name of Responsible Certified Applicator: Signature of Responsible Certified Applicator: GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS --------0-------- DEPARTMENT OF PLANNING AND NATURAL RESOURCES ENVIRONMENTAL PROTECTION DIVISION 4611 Tutu Park Mall 45 Mars Hill, Frederiksted Suite 300, 2nd Floor St. Croix, VI 00840 St. Thomas, VI 00802 (340) 773-1082 (340) 774-3320 dpnr.vi.gov