"Application for Pesticide Application Business Licence" - Prince Edward Island, Canada

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Application for
Pesticide Application
Business Licence
Under section 28 of the Pesticide Control Act Regulations, a person who operates a business or provides a service that
involves the application of a domestic or non-domestic pesticide for a fee must hold a Pesticide Application Business Licence.
Personal information on this form is collected under section 5 of the Pesticide Control Act Regulations as it relates directly
to and is necessary for an application for a Pesticide Application Business Licence. Personal information may be disclosed
to third parties in accordance with provincial legislation. If you have any questions about this collection of personal
information, you may contact the Pesticide Regulatory Program, 11 Kent Street, Jones Building, Charlottetown, PEI
C1A 7N8, (902) 368-5599.
Applicant Contact Information
Company Name:
Contact Name:
Phone:
Fax:
Mailing Address:
Civic Address:
Postal Code:
Email:
Licence Class (check one)
G Class A, Agricultural – operating ground agricultural equipment for pesticide application
G Class B, Mosquito & Biting Fly – application of a pesticide for the control of mosquitoes or biting flies
G Class C-1, Structural – application of a non-fumigant pesticide to stored feed, dwellings or other structures
G Class C-2, Structural Fumigation – application of a fumigant pesticide to stored feed, dwellings or other structures
G Class D, Seed/Seed-piece Treatment – application of a seed or seed-piece treatment pesticide
G Class E, Landscape – application of a pesticide to ornamental vegetation
G Class F-1, Forestry Herbicides – forestry herbicide application
G Class F-2, Reforestation – application of a pesticide for the production of tree seedlings for reforestation purposes
G Class G, Greenhouse – application of a pesticide in greenhouses
G Class H, Soil Fumigation – application of a soil fumigant pesticide
G Class I, Other – other pesticide applications
G New Applicant
G Renewal of Licence
Present Licence Number:
Certified Applicator Information (Pesticide Applicator Certificate Holder)
Name:
Phone:
Fax:
Mailing Address:
Civic Address:
Postal Code:
Email:
G Owner of Company
G Employee of Company
Certified Applicator Status:
Certificate Class and No.:
Certificate Expiry Date:
Signature of Certified Applicator:
Date:
(if not company owner)
Applicant’s Signature:
Date:
(Where applicant is a partnership or a corporation, the signature of a partner, or an authorized officer of the corporation is required.)
Over !
Application for
Pesticide Application
Business Licence
Under section 28 of the Pesticide Control Act Regulations, a person who operates a business or provides a service that
involves the application of a domestic or non-domestic pesticide for a fee must hold a Pesticide Application Business Licence.
Personal information on this form is collected under section 5 of the Pesticide Control Act Regulations as it relates directly
to and is necessary for an application for a Pesticide Application Business Licence. Personal information may be disclosed
to third parties in accordance with provincial legislation. If you have any questions about this collection of personal
information, you may contact the Pesticide Regulatory Program, 11 Kent Street, Jones Building, Charlottetown, PEI
C1A 7N8, (902) 368-5599.
Applicant Contact Information
Company Name:
Contact Name:
Phone:
Fax:
Mailing Address:
Civic Address:
Postal Code:
Email:
Licence Class (check one)
G Class A, Agricultural – operating ground agricultural equipment for pesticide application
G Class B, Mosquito & Biting Fly – application of a pesticide for the control of mosquitoes or biting flies
G Class C-1, Structural – application of a non-fumigant pesticide to stored feed, dwellings or other structures
G Class C-2, Structural Fumigation – application of a fumigant pesticide to stored feed, dwellings or other structures
G Class D, Seed/Seed-piece Treatment – application of a seed or seed-piece treatment pesticide
G Class E, Landscape – application of a pesticide to ornamental vegetation
G Class F-1, Forestry Herbicides – forestry herbicide application
G Class F-2, Reforestation – application of a pesticide for the production of tree seedlings for reforestation purposes
G Class G, Greenhouse – application of a pesticide in greenhouses
G Class H, Soil Fumigation – application of a soil fumigant pesticide
G Class I, Other – other pesticide applications
G New Applicant
G Renewal of Licence
Present Licence Number:
Certified Applicator Information (Pesticide Applicator Certificate Holder)
Name:
Phone:
Fax:
Mailing Address:
Civic Address:
Postal Code:
Email:
G Owner of Company
G Employee of Company
Certified Applicator Status:
Certificate Class and No.:
Certificate Expiry Date:
Signature of Certified Applicator:
Date:
(if not company owner)
Applicant’s Signature:
Date:
(Where applicant is a partnership or a corporation, the signature of a partner, or an authorized officer of the corporation is required.)
Over !
The application fee for a Pesticide Application Business Licence is $200.
A separate application is required for each licence applied for.
A copy of the insurance policy required by clause 5(1)(a) of the regulations (limited pollution liability and general
public liability) must accompany all applications.
Payment must be received by the department before the application will be processed.
Method of Payment (Check appropriate box)
Please forward application and payment to:
G Cheque
Department of Communities, Land and Environment
G Money Order
Pesticide Regulatory Program
G Cash or Debit Card
PO Box 2000, 11 Kent Street
G Credit Card
Charlottetown, PE C1A 7N8
Amount Enclosed: $________________
Tel: (902) 368-5599
Cheques or money orders should be made payable to the Minister of Finance.
Pesticide Application Business Licences will be mailed to the applicant’s address above.
Please allow two weeks for delivery.
15EN15-42283
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