California Form Dpr 035 – Fill Out and Use This PDF

Applicant Information			Important: Read all instructions before completing this form.
1.	Firm Name
2.	Mailing Address of Firm	Check box if updated address		City	State	Zip Code
3.	Street Address (if different from above) or Agent Address			City	State	Zip Code
4.	Name of Authorized Representative
5.	Telephone Number of Representative		6. Fax Number		7. E-mail Address
	( )		( )

Product Information

8.Product Brand Name (exactly as shown on label)

9.U.S. EPA Registration Number (or California Registration Number for Spray Adjuvants)

10.Type of California amendment action requested that must be supported by scientific data.

Addition of a crop. Addition of sites or uses. Addition of indoor use.

Adding the first agricultural use for the active ingredient. Adding pests or types of pests not already on the label. Reducing the signal word or the precautionary statements. Other (explain in cover letter).

NOTE: Minor amendments not requiring scientific data are not subject to the fee and do not require an application form.

I certify, under penalty of perjury, that all information submitted on this application to amend pesticide product is accurate and complete.

X_____________________________________ / _____________________________________________/ ____________________

Signature of Authorized Representative

Type or Print Name/Title

Date Signed

DPR-035 (05/06)

Page 2 of 2

INCOMPLETE FORMS WILL NOT BE PROCESSED.

If any section does not apply to your product, please mark it N/A. A separate application form must be completed for each amendment for each product brand name. If you need further assistance, contact the Pesticide Registration Branch at (916) 445-4400.

PRODUCT INFORMATION

1.Firm Name: This must be the same as on file with U.S. EPA.

2.Firm Mailing Address: Correspondence, licenses, notices, etc. will be sent to this address.

4.Name of Authorized Representative: The person who is authorized to answer any questions about your application for registration. Generally, this is the person who prepares the application. If the person is an agent, a letter from the firm authorizing

the agent to act on their behalf is required.

7.E-mail address: In accordance with California Notice to Registrants 2005-4, supplying DPR with this information will automatically enroll the applicant (firm or agent) into the automatic notification program. Applicants that do not wish to receive these automatic email updates must specify this in their cover letter or on the application form.

8.Product Brand Name: This must be EXACTLY the same as the brand name registered (or, if applicable, received) by U.S. EPA and the same as on the product labeling. The product brand name cannot be the same as another product, within the same company, with a different formulation. Do not include symbols used in place of words that are part of the brand name (e.g. @, TM, *, (R), etc.).

9.U.S. EPA Registration Number: Required unless product is exempt from, or does not require, registration under the Federal Insecticide Fungicide and Rodenticide Act (FIFRA) such as spray adjuvant. For a spray adjuvant, the California Registration

Number is required.

10.Type of California Amendment Action Requested:

*Adding sites or uses:

*Adding a crop:

*Adding indoor use:

*Adding the first agricultural use for the active ingredient:

*Adding pests or types of pests not already on the label:

*Reducing the signal word or the precautionary statements:

*Other: Please attach a cover letter explaining the type of registration action requested.

An Amendment Application Package must include the following:

Information Available on the Internet

Information about the California laws and regulations governing pesticide registration, as well as Department notices, policies and procedures is available on the internet at <http://www.cdpr.ca.gov>. Information on currently registered products, registrants, telephone numbers for Department staff, and other information is also available at this site.

Persons interested in receiving notices specific to registration issues must subscribe to the e-mail list or access the “California Notices to Registrants” web page found on the Departments’ website.

To subscribe to “California Notices to Registrants” for e-mail delivery, visit the E-List page at <http://www.cdpr.ca.gov/docs/listserv/listdesc.htm>, and click on the subscribe link under the list name. An alternate method of subscribing is to send an e-mail to canote-request@pestreg.cdpr.ca.gov and put the word “subscribe” in the subject line. You will receive an e-mail, welcoming you to the list. To access new and historical notices via the Internet, see <http://www.cdpr.ca.gov/docs/canot/camenu.htm>.