Product Registration
Application For An Experimental Use Permit

In accordance with regulations promulgated pursuant the Massachusetts Pesticide control Act (333 CMR7.05) this application for an Experimental Use Permit must be completed in full and filed/with the Pesticide Board Subcommittee along with experimental label, a copy of the EPA Experimental Use Permit and the permit fee of one hundred dollars ($100.00) and such other information as the Subcommittee may require. The fee is payable by check or money order to the Commonwealth of Massachusetts and shall be waived for applications by government agencies.

PLEASE SUBMIT TWO COPIES

Date of Application _______/______/_______

Part I: Product Identification
1. Name and Address of Applicant Signature of Applicant or Authorized Representative
Title
Telephone
2. Product Name 3. Product Type
4. Registration Number of Product if Registered with EPA
5. Federal Experimental Permit Number if Issued by EPA
6. Effective Date of EPA Permit _______/________/__________ to ______/______/________
7. Quantity Authorized by EPA

Part II: Purpose or Objectives of Proposed Testing

Part III: Proposed Experimental Program

1. Designation of pest organism(s)
2. Amount of pesticide proposed for use
3. Method of application
4. Proposed dates or periods during which the testing program is to be conducted
5. Location of application(s)
6. Manner in which supervision of the program will be accomplished
7. Description of application (include information such as crops, sites,dosage rates and situation of application on or in which the pesticide is to be used)
8. Proposed method of storage and disposition of any unused experimental use pesticide and its containers
9. Disposal of treated crop - Proposed method of disposal of a treated commercial crop that does not meet environmental agency tolerance for that corp or for which no tolerance has been set

Part IV: Program participant(s) and Cooperator(s)
List all participant(s) in the program, whether or not in the employ of the applicant. Include name, street address, telephone number and qualifications of participant(s). The qualifications of the participant(s) must include participant(s) current Massachusetts Category 49 (Research and Demonstration) certification number.

Part V: Submission of Available Toxicological Data
Please submit with this application any toxicological data available. These may include but not be limited to: Acute Toxicity Information (summarize and attach reports); include rat oral LD50 and rabbit dermal LD50 if available; Chronic Toxicity Information (summarize and attach reports): Oncogenic studies, Mutagenic studies, Reproductive studies, Neurotoxic studies, Other chronic studies; Any existing health based guidelines (EPA, ADIs, FDA, WHO, etc.), Exposure information, such as levels that have been found in drinking water, foods, air, or in applicator studies; Attach an updated bibliography concerning the toxicity of the pesticide, including any review articles such as those by the FAO/WHO, EPA, FDA, and others.List each item below.

Part VI: Submission of Available Environmental Fate Data

Please submit with this application any environmental fate data available. This may include but not limited to: degradation studies, metabolism studies, mobility studies, dissipation studies and accumulation studies. (40 CFR 160-165).List each item below.

Registration Pesticide Bureau