ATTACHMENT G: PESP Membership Application_EPA Form No 9600-02

ATTACHMENT G

PESP Membership Application

Note: The form below is a reproduction of a form that was developed for online use.

By completing this application for membership in PESP, we affirm our commitment to the following:

We believe that environmental stewardship is an integral part of pest management practices and will continue to work toward pest management practices that reduce the risks to humans and the environment. As part of our voluntary participation in the Pesticide Environmental Stewardship Program, this organization will develop a Strategic Approach to pesticide risk reduction and implement annual Activities that fall within this Strategic Approach.

We understand that in return, the U.S. Environmental Protection Agency will seek to foster, fund and promote, through research, education, and other means, the adoption of alternative pest management technologies and practices that enhance pest management and reduce pesticide risk.

* = required

Contact Type*

Salutation*

First Name* Last Name*

Company*

Title*

Email*

Phone* (number only - no dashes or spaces)

Fax (number only - no dashes or spaces)

Address*
City* State/Province* Zip*

Industry*

Secondary Contact Information

Overview & Mission of Your Organization*
Please provide an overview of your organization (e.g., history and size, nature of services offered, number of customers or acres managed, environmental/IPM activities and/or certifications, etc.) and your environmental stewardship mission. How do your organization’s activities and mission currently relate to IPM? (Maximum length: 10,000 characters)

Why are you interested in joining PESP?*
Please explain your organization's interest in joining PESP. How do you hope to be engaged as a PESP member, and what do you hope to gain from PESP membership? Please also let us know how you heard about PESP. If you were referred by an existing PESP member or partner, please provide the individual's name.(Maximum length: 10,000 characters)

OMB Control No. 2070-XXXX

EPA Form No. 9600-02

Approval Expires XX-XX-XXXX