Ohio Department of Agriculture
PLANT INDUSTRY / Pesticide and Fertilizer Regulation Section
8995 East Main Street, Reynoldsburg, OH 43068-3399
Telephone: (614) 728-6397 Fax: (614) 728-4221
www.ohioagriculture.gov/plant Email: pesticides@mail.agri.state.oh.us
APPLICATION FOR REGISTRATION OF PESTICIDE
PRODUCTS
Section 921.01 to 921.31, inclusive, of the Revised Code of Ohio: Application is hereby made for the registration of the following
th
pesticides for the periods listed above, through June 30 of the application year. Information as required by law, is submitted in the
attached individual product labeling.
SUBMITTED BY: SUBMITTED FOR:
FIRM: FIRM:
CONTACT:
ADDRESS 1:
ADDRESS 2:
CITY: STATE: ZIP:
TELEPHONE: EMAIL:
SIGNATURE: DATE SIGNED:
PAYMENT REQUIRED:
Remittance of $150.00 per each brand OR product name payable to the Ohio Department of Agriculture must be enclosed.
Payment by check, money order, or credit card only:
, .
$
X $150.00 =
Number of Products:
Check # Money Order Visa Mastercard
Payment Method:
If paying with credit card, the following information is required before payment can be processed:
Name on Credit Card:
- - -
Credit Card Number:
(MM) (YYYY)
Expiration Date:
Signature (required):
For Instructions, please see back
Product Name and Brand (as on label) with Active Ingredients Federal Registration Number
PLNT-PF-4204-001.pdf (12/29/06)
Ohio Department of Agriculture
PLANT INDUSTRY / Pesticide and Fertilizer Regulation Section
8995 East Main Street, Reynoldsburg, OH 43068-3399
Telephone: (614) 728-6397 Fax: (614) 728-4221
www.ohioagriculture.gov/plant Email: pesticides@mail.agri.state.oh.us
APPLICATION FOR REGISTRATION OF PESTICIDE
PRODUCTS
Instructions for Registering Pesticide Products
Supplement to Form 4204-001
1. Fill out the Application for Registration of Pesticides (Form 4204-001) completely and include your signature.
2. Include one completed application only in your submission. No copies are required.
3. Include check, money order, or credit card information for $150.00 per product. (Example: 10 products at a cost of
$150.00 each product equals a payment in the amount of $1500.00.)
4. Payment should be made to Ohio Department of Agriculture.
5. New Products: Include an EPA approved label or copy of same for each product. If you cannot obtain a label,
submit the EPA approval sheet along with the text sent to EPA. Include only one copy of the label. Product
labels and MSDS sheets on CD's in PDF format will be accepted.
6. Currently Registered Products: Labels and MSDS are not required if we have a current label and MSDS sheet
on file. Labels that have changes of Product Name or Manufacturer (etc) need to be re-submitted. Revised
product labels and MSDS on CD's in PDF format will be accepted.
7. Include an MSDS sheet for each product. Do not staple the MSDS sheet to the label.
8. Send the application, labels, MSDS's and payment in the same mailing.
STEPS 1 THROUGH 5 AND 7 ABOVE MUST BE COMPLETED BEFORE WE CAN REGISTER YOUR PRODUCTS.
Deleting Products: If your company no longer wishes to register a product, please make a line through the product
listing and its EPA Registration Number on the form using a straight edge or ruler.
Restricted Use of Producats: If a pesticide is classified as restricted-use, please mark it with an asterisk.
New Pesticide Registration: If there is insufficient space to list new pesticide products, a supplemental sheet
can be attached.
No Longer Distribute Any Pesticides: If your company no longer has any pesticide products in the channels
of trade in Ohio, please let us know by lining through all products on the renewal form and returning it OR call the
department and we will delete your company from our files.
PLNT-PF-4204-001.pdf (12/29/06)
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