Fillable Arizona Department of Agriculture (Arizona)

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Arizona Department of Agriculture (Arizona)

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The Arizona Department of Agriculture (Arizona) form is 3 pages long and contains:

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  • 0 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

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Rev Date 3-20-18
DOUGLAS A. DUCEY
Governor
MARK W. KILLIAN
Director
Arizona Department of Agriculture
Pest Management Division
1688 W. Adams Street, Phoenix, Arizona 85007
(602) 255-3664 / e-mail opmcompliance@azda.gov
Complaint Form
Your Contact Information
Name
Street Address
City, State, Zip Code
Home Telephone Number
Business Telephone Number
Cell Phone Number
E-Mail
Nature of the Event/ Observation (Check Box if Applicable)
Possible Health Issue (If yes,
have you sought medical
attention?)
Possible Unlicensed
Possible Misuse of a Pesticide
Possible Treatment Issue
(excluding warranty or efficacy)
Other (Please Specify)
Event / Observation Information
Date of Event
Location of Event
Time of Event
--
Rev Date 3-20-18
Complaint Against
Name of Business/ Individual
Address of Business or
Individual
Business License Number
Telephone Number(s)
Vehicle Information (If applicable)
Make, Model , Color
License Plate
Statement of Event/ Observation
Please be specific. (Attach additional pages, photographs or documentation as needed).
*Note: Please be advised this Agency has no statutory authority
regarding efficacy, price, or contractual matters. Also note pesticide
registration is approved on a Federal level by the Environmental
Protection Agency, and as such this Agency has no statutory authority
to prohibit lawful applications of any registered pesticide.
Oftentimes, a complaint can be resolved before we begin our
investigation. Have you attempted to contact the company to resolve
the matter?
--
Rev Date 3-20-18
What do you expect of this Agency?
Submitted by:_____________________ Signature _________________________
Today’s Date______________________
Upon receipt of this completed form, we will review this information to determine if
this matter is one in which we have statutory authority. If so deemed, an
Investigator will contact you to schedule an interview.
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Arizona Department of Agriculture (Arizona)

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Completed 20 July 2020

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