INSPECTORATE OF PUBLIC HEALTH Department of Health Protection Schouwburgweg # 24, APNA-building (P.O. Box 3824) Curaçao. Telephone : 5999-4669366 Fax : 5999-4669367 PESTICIDE APPLICATION FORM Undersigned, located at notifies the Inspector of Health Protection of his intention in marketing the pesticide (name pesticide) Signed:.., at... (Date) (Place). (Signature) Application number : Name of the Pesticide : Application date : Use classification : Formulation : Applicant Name : Telephone number : Fax number : Contact person : Producer Name : City : Country : (for official use ) 1
FOR MORE INFORMATION, PLEASE REFER TO THE EXPLANATORY NOTES. PART A: GENERAL INFORMATION Answer the A-questions only on this form. A.1. Name : Telephone number : Contact person : A.2. Name and address of the manufacturing company of the pesticide for which authorization is required. Name : City : Country : Telephone number : Fax : A.3. Name of the product as it will appear on the packaging. A.4. Chemical and/or common name (ISO-name) of the active ingredient(s). 2
A.5. Brief description of intended use. A.6. Form in which the product is supplied and its net weight. A.7*. Country(ies) in which the pesticide has already been approved, registered or authorized. This question has to be answered in case that the pesticide to be registered does not contain EPA#. When EPA# is available, record the # here: When no EPA# is available the countries in which the pesticide has already been approved must be recorded and a copy of the certificate of competent authority of land of origin has to be attached as appendix to this application. Record the countries and send a copy of the certificate. Countries in which the pesticide has already been approved: (Appendix: Certificate of competent authority of land of origin; this is needed when the product does not contain an EPA#) 3
PART B: DATA OF THE ACTIVE INGREDIENT(S). A separate part B has to be filled in for every active ingredient. Make sure you have a copy of the MSDS of the active ingredient(s); it is with the MSDS that the following questions can be answered. B.1. Chemical name and common name of the active ingredient. B.2. Manufacturer of the active ingredient. B.3*. Physical and chemical properties of the active ingredient. (Appendix: MSDS of the active ingredient) B.4. Empirical formula, and molecular weight. Search for this information on the web in case that this information can not be found on the MSDS of the active ingredient. 4
PART C: DATA OF THE COMPOSITION OF THE FORMULATED PESTICIDE (THE COMMERCIAL PRODUCT) Make sure you have a copy of the MSDS of the commercial product; it is with the MSDS that the following questions can be answered. C.1*. Complete composition: active ingredients and inert ingredients. Chemical name or common name of all constituents (Underline the active ingredients) Content/ amount Mass % and/or gram/ liter 1 2 3 4 5 6 The summary of mass % must be 100% An EPA# is essential in case that the inert ingredients can not be identified. EPA#: (Appendix) C.2*. a Analysis method to determine the presence of the active ingredient in the composition of the pesticide. b Laboratory result which guarantees the amount of active ingredient claimed on the label. This can be ignored if the pesticide contains an EPA#. EPA#: (To be submitted as an appendix) 5
C.3*. Physical and chemical properties of the commercial product. C.4*. Stability and Shelf life at 25 C. (Appendix: MSDS of the commercial product) (Appendix: MSDS of the commercial product) C.5. Are there products or substances with which the pesticide is incompatible? PART D: DATA OF INSTRUCTION FOR USE D.1*. Draft instruction for use. (Appendix, photocopy of the label) When non-conventional equipment is needed, attach an appendix describing the particular equipment. D.2. Circumstances which have influence on effectiveness of the product. D.3. Type and size of the package and method of closure. 6
D.4. Are the containers (packaging) intended to be reused or refilled? D.5. Instructions for disposing of spillage or old stock. (See MSDS of the product) D.6. Ways of disposal of the empty containers or packages. (See MSDS of the product) 7