Application For Registration Of Pesticides Form - Mississippi Department Of Agriculture And Commerce

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(Submit in Duplicate)
Mississippi Department of Agriculture and Commerce
Bureau of Plant Industry
P.O. Box 5207
Mississippi State, Mississippi 39762
Ph. (662) 325-3390
*******
Application for Registration of Pesticides
Under the Mississippi Pesticide Law of 1975
Application for registration of the pesticides named below is hereby filed with the Bureau of Plant Industry. Specific
information as required by law is submitted in the attached individual documents. (See instructions on reverse side.)
Remittance payable to the Bureau of Plant Industry in the amount of $
is enclosed herewith to cover annual registration
fees for
brands or grades. (Fees: One hundred dollars for each brand or grade.)
Address Correspondence to:
Submitted by:
Firm
Firm
Attention
by
Street & No.
Telephone No.
Post Office Box No.
Fax No.
City, State & Zip
Certificate of Registration
When signed under authority of the Bureau of Plant Industry, this certifies that the brands or grades of pesticides named below
have been duly registered, registration fees paid therefor and their sale in Mississippi authorized, from the date of registration
through the next coming December 31, according to provisions of sections 69-23-1 through 69-23-27, Mississippi Code of 1942
as amended by Laws of Mississippi, 1987.
Date of Registration
Bureau of Plant Industry
Receipt No.
By
Brands or Grades (See Instructions)
EPA Registration No.
(For additional space attach permanently 8 1/2" by 11" Page)

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