Fillable Pesticide Product Registration Application (New York State)

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Pesticide Product Registration Application (New York State)

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The Pesticide Product Registration Application (New York State) form is 2 pages long and contains:

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Division of Materials Management
New York State Department of Environmental Conservation
625 Broadway, Albany, NY 12233-7257
Pesticide Product Registration Application
Initial Basic Registration
Experimental Use Permit
New Active Ingredient
Major Change in Labeling
Special Local Need
Supplemental Distributor Registration
1. Registration Type (Refer to the instructions and application checklists on the next page)
Office Use Only
Payor
EPA Company Number
Company Name
Mailing Address
City State Zip Code
3. List Pesticide Products Below (Attach additional sheets if necessary)
EPA REG. NO. PRODUCT NAME
Name of Registering Official (Please Print)
Date
Phone
Email
I certify that the information supplied herein is accurate, complete and a true representation of the enclosed application and in compliance
with 6NYCRR Part 326. I also understand that I may be subject to criminal penalties for willfully concealing, misrepresenting or
falsifying facts on this application.
http://www.dec.ny.gov/chemical/8528.html
Signature ______________________________________________
E-mail: ppr@dec.ny.gov
Pesticide Product Registration Section
2. Company Information
4. Registering Official
Payment enclosed Send me an invoice
or
Check off the following items to be included with your registration application (* denotes this item is needed
for each product on the application). Please note that incomplete applications will be returned.
Instructions
This is a fillable form. All necessary fields (except signature) may be filled using Adobe Acrobat. This form may also be printed
and filled by hand. When filling electronically, use the Tab key to advance to the next field. Please do not make any marks in the
Office Use Only box. Please call the Pesticide Product Registration Section at (518) 402-8768 or email ppr@dec.ny.gov with
any questions.
1. Check the appropriate registration type. Please visit the Pesticide Product Registration webpage
(http://www.dec.ny.gov/chemical/8528.html) for more information regarding application types.
2. Enter the EPA Company Number of the company who will be responsible for the registration. Enter the company name,
mailing address, city, state and zip code of the registering firm (where correspondence/registration certificates will be sent).
3. Enter the EPA registration number and product name for all products being registered. If more than eight products are being
registered, please attach additional sheets.
4. Print the name, phone number and email address of the company's registering official. Sign and date the application.
5. Consult the checklists below regarding application requirements.
6. Application fees are $620* per product. Payment options: Either include a check (payable to Commissioner, NYSDEC)
for the non-refundable application fee or the Department will send you an invoice via email. The invoice allows your
company to pay via physical check, electronic check, debit card or credit card. Please note that transaction fees are added
to certain payment types.
*If your company's gross annual sales (for the entire company) are $3.5 million or less, the fee is $600 per product provided that
you submit a copy of the front page of your company's most recent annual federal income tax return with your application.
Otherwise you will be invoiced $620 per product.
Initial Basic New Product Supplemental Distributor New Product
New Active Ingredient/Major Change in Labeling
Special Local Need
Experimental Use Permit
*Notice of Supplemental
Distribution (EPA Form 8570-5)
*Copy of ABN (if applicable)
*CSF (EPA Form 8570-4) on CD
*1 Paper Copy (double-sided) of Final Label
*1 Paper Copy (double-sided) of EPA
Stamped Accepted Label and Applicable
Notifications
*NY Product Information Form
Application Form
Check or Department will email invoice
*CSF (EPA Form 8570-4) on CD
*1 Paper Copy (double-sided) of EPA
Stamped Accepted Label and Applicable
Notifications
*NY Product Information Form
Application Form
*SLN Justification
*Supporting Data for SLN on CD
*1 Copy of EPA Application for
SLN (EPA Form 8570-25) on CD
*1 PDF of Proposed SLN Label on CD
Check or Department will email invoice
*CSF (EPA Form 8570-4) on CD
*1 Paper Copy of Final Product Labeling
*1 Paper Copy of EPA Stamped Label
*NY Product Information Form
Application Form
*Data Summaries If Active
Ingredient Not Registered in NY
Check or Department will invoice
*Supervisor and Cooperators
*Final EUP Label on CD
*Paper Copy of Federal EUP Label
*NY Product Information Form
Application Form
*1 PDF of Final Label on CD
*1 PDF of Final Label on CD
Check or Department will email invoice
*Proposed EUP Program in NY
*Data Summaries (4 CDs)
*EPA Review Documents (4 CDs)
Check or Department will email invoice
*Safety Data Sheet (4 Paper Copies)
*CSF (4 Paper Copies)
*Final Product Label (4 Paper Copies)
*EPA Stamped Label(s) (4 Paper Copies)
*NY Product Information Form (4 Paper Copies)
Application Form (4 Paper Copies)
*1 Paper Copy (double-sided) of Final Label
*Compact Disk Containing Electronic
Copy of Final Product Label and CSF
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Pesticide Product Registration Application (New York State)

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Completed 23 August 2020

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