IR-4 Minor Use Project Clearance Request Form

This information is entered automatically into a request database and email notification is sent to the appropriate IR-4 personnel.

If you submit incorrect information or need to modify your request, please contact IR-4 personnel at (732) 932-9575 ext. 4611 or email Susan Bierbrunner

Please note blue fields are required.

1. REQUESTER
Name:
Affiliation:
Address:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:

2. PESTICIDE (Common Name):


2a. Have you spoken with a registrant about this request? If so, which registrant? We highly encourage you to discuss your need with a registrant before submitting this request form!


3. COMMODITY

Crop:
Use Site:
Parts Consumed:
Animal Feed By-Products:
Planting Season:
Harvest Season:
Local Acreage:
% National Acres:


4. POTENTIAL INTERNATIONAL CONSIDERATIONS:

Is this an export commodity: Yes    No   Likely   Not Certain
Key Export Markets:
Are there MRLs established in
key export markets?:		 Yes    No   Likely   Not Certain
  Which markets?:



5. TARGET PESTS/POTENTIAL EFFECTS:

6. WHY IS THIS USE NEEDED:


7. COMPATIBILITY OF THIS USE WITH IPM: (See Western Region IR-4 website for IPM-fit guidance):

Does this use have a good fit in IPM?: Very Good Fit    Good Fit   Fair Fit Poor Fit   Very Poor Fit   Unknown
Provide an explanation of the fit (e.g. relatively nontoxic to beneficials; application timing compatible with pest monitoring; useful in controlling populations with established pesticide resistance; use is compatible with cultural pest management practices; pesticide plays a significant role in an existing IPM program; list unique attributes of this pesticide use). See Western Region IR-4 website for IPM-fit guidance.



8. PROPOSED LABELLING:

Trade Name
Dosage Rate (Active/Acre)
Type Of Application (e.g. foliar, soil, seed treatment, etc):
Number of Applications:
Re-treatment Interval (Days):
PHI (days):
Directions of Use
Limitations
Special Safety Precautions


9. ARE YOU SUBMITTING SUPPORTING DATA *
Phytotoxicity (P): Yes    No
Efficacy (E): Yes    No
Yield (Y): Yes    No
*Send email with attachments to Susan Bierbrunner after submission of this form.