MISSISSIPPI DEPARTMENT OF AGRICULTURE AND COMMERCE
BUREAU OF PLANT INDUSTRY
Phone (662) 325-3390
APPLICATION FOR REGISTRATION AND/OR REREGISTRATION OF PESTICIDES
Mississippi Pesticide Law of 1975: Sections 69-23-1 through 69-23-29, Mississippi Code 1972
Complete this application for registration of the pesticides named below and return to the Bureau of Plant Industry, P.O. Box 5207,
Mississippi State, MS 39762. See the pesticide registration instructions for completing this application.
TYPE OR LEGIBLY PRINT ALL INFORMATION
Enclose payment to the Bureau of Plant Industry for $__________ ($200 per brand) to cover annual registration fees for __________
pesticide brands. Make check or money order payable to MDAC.
SEND CORRESPONDENCE TO:
Company Name:_______________________________ Firm:______________________________________
Contact Person:________________________________ Contact Person: _____________________________
Address: _____________________________________ Address:___________________________________
City, State, and Zip:_____________________________ City, State, and Zip:__________________________
E-Mail Address_________________________________ E-Mail Address_____________________________
Phone No:_________________Fax:________________ Phone No._________________Fax:_____________
APPLICATION FOR REBATE OF REGISTRATION FEES FOR PRODUCTS PRODUCED IN MISSISSIPPI
I, hereby, apply for rebate of pesticide registration fees in the amount of $__________($100.00 per brand) for _________ number of
pesticide product(s) so designated (check-box) on the attached page(s).
I am submitting a notarized statement declaring truthfully that said products have been/shall be produced in Mississippi during
the calendar year for which registration is requested. To meet this requirement, I the applicant, shall allow an inspection by the
Bureau of Plant Industry during normal business hours of any and all establishments.
THIS SECTION FOR BUREAU OF PLANT INDUSTRY USE ONLY
CERTIFICATION OF REGISTRATION
When signed by an authorized employee of the Bureau of Plant Industry, this certifies the brands/products so named on the attached
document have been duly registered, registration fees have been paid, and the sale and use of each product in Mississippi is authorized
through December 31, 2005.
SUBMIT IN DUPLICATE