Request For Pesticide Registry Or Pesticide Application Information - New York State Department Of Health
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8October 2010
REQUEST FOR PESTICIDE REGISTRY
OR PESTICIDE APPLICATION INFORMATION
NEW YORK STATE DEPARTMENT OF HEALTH
HEALTH RESEARCH SCIENCE BOARD
I.
ORGANIZATION AND INDIVIDUAL REQUESTING PESTICIDE REGISTRY
INFORMATION OR PESTICIDE APPLICATION INFORMATION:
A.
Project Director:___________________________________________________
B.
Position Title:______________________________________________________
C.
Organization: (include Branch, Division, Department, etc.):
_________________________________________________________________
D.
Street address or PO Box:____________________________________________
E.
City/State/Zip Code:_________________________________________________
E.
Telephone (Area Code):_____________________________________________
FAX #:______________________ E-mail Address:_______________________
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