1222E (2017/12) © Queen's Printer for Ontario, 2017 Disponible en français Page 1 of 5

Ministry of the Environment and Climate Change

Application for a Vendor Licence for Pesticide Sales General Information and Instructions

GeneralInformation requested in this form and supporting documentation is collected under the authority of the Pesticides Act and Ontario Regulation 63/09 and will be used to evaluate applicants for Limited, General, and Treated Seed Class 12 Vendor licences according to the requirements of the Pesticides Act. The personal information collected in this application will be used to administer the pesticides licensing program, including for the purposes of the Ministry’s compliance and enforcement activities under the aforementioned act, and for the purposes of making information available to the public, as governed by the Freedom of Information and Protection of Privacy Act (FIPPA). Questions about the collection of this information can be directed to a Client Service Representative, Client Services and Permissions Branch (CSPB), Ministry of the Environment and Climate Change (MOECC), 135 St Clair Ave W, 1st Fl, Toronto, ON, M4V 1P5; telephone outside Toronto 1 800 461-6290 (toll free) or in Toronto 416 314-8001, fax 416 314-8452 or email MOECCpermissions@ontario.ca.

A complete application consists of:a) The completed and signed application form.b) Proof of Legal Name (such as a copy of the Master Business Licence).c) A certified cheque, money order or credit card payment for the amount specified on the application form.d) Proof of Certification for the Ontario Certified Outlet Representative (General Vendor Licence Application Only).e) List of Sales Representatives (Treated Seed Class 12 Vendor Licence Application Only).Incomplete applications will be returned to the applicant.

Instructionsa) Applicants are responsible for ensuring that they complete the most recent application form. When completing this form,

please refer to the publication titled “Guide to Pesticide Licensing and Certification” (PIBS 4523). Application forms and supporting documentation are available from the CSPB, from your local MOECC District Office, and in the “Resources” section of the MOECC’s website at: http://www.ene.gov.on.ca/environment/en/category/pesticides/STDPROD_079357.html

b) Questions regarding completion and submission of this application should be directed to the CSPB or to your local District Office of the MOECC.

c) Please forward the completed application along with your fee and any supporting information by fax to 416 314-8452 or by mail to (do not submit by email): Pesticides Licensing Client Services and Permissions Branch Ministry of the Environment and Climate Change 135 St Clair Ave W, 1st Fl, Toronto, ON M4V 1P5

d) The Pesticides Act states that unless exempt by regulations, no person shall sell or offer to sell any pesticide unless the pesticide is classified by the regulation and except under and in accordance with a prescribed licence for each facility from which the pesticide is sold or offered for sale. Please note: a separate application is required to be completed for each facility.

e) There are three classes of Vendor licences, General, Limited, and Treated Seed. The licences are issued for a five year period at a cost of $200.00 for the General Vendor licence and Treated Seed Vendor Licence, and $110.00 for the Limited Vendor licence. A certified cheque, money order or credit card payment must be made payable to the Ontario Minister of Finance. Other methods of payment will not be accepted. For more information about the requirements and restrictions associated with General and Limited Vendor licences, please refer to the “Guide to Pesticide Licensing and Certification” (PIBS 4523).

f) Each facility applying for a General Vendor licence (not Limited) must have a Certified Outlet Representative who works full time at the sales outlet. This Outlet Representative must either have successfully completed the Pesticides Vendor Certification Course (PVCC) or been recertified or, if originally licensed as a vendor/dispenser in another province or territory, then have been granted an Ontario Outlet Representative certificate from Ridgetown Campus, University of Guelph, within five years of submitting this application. The PVCC is administered by Ridgetown Campus, University of Guelph, which is the provincially recognized educational institution for certification of an outlet representative. For information regarding certification please call 1 800 652-8573 or 1 519 674-2230. Proof of a certified Ontario Outlet Representative must accompany the application for a General Vendor licence.

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g) Limited, General, and Treated Seed Vendors must notify the MOECC of any changes to the information contained in this application in writing within 10 days of the change as per the Ontario Regulation 63/09. Please use the “Pesticide Licence Information Update Form” (PIBS 4890) available on the MOECC website as above.

h) A licensed Vendor that stores Classes 1 to 8 pesticide products for sale must provide written notice of this pesticide storage annually to the Fire Department responsible for the area in which the pesticide is stored.

i) If the applicant is a corporation or partnership, it shall designate on its application an official representative who is at least 18 years of age and is authorized to sign the application.

j) For definition purposes, the “CRA Business Number” referred to in section 1 of this application is the number assigned to all registered business names by Ministry of Consumer & Business Relations.

k) Information not flagged as confidential in Section 5 of the application may be made available to the public upon request.

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Ministry of the Environment and Climate Change

Application for a Vendor Licence for Pesticide Sales (General, Limited and Treated Seed)

For Office Use OnlyLicence Number Billing Number

1. Applicant InformationBusiness OwnerLast Name First Name Middle Initial

Company InformationBusiness Name (legal name of individual or organization as evidenced by legal documents) Business Identification Number

Trade Name (the common name that the individual or organization operates under, if different than the business name)

Mailing AddressApt/Suite Number Street Number Street Name PO Box

Lot/Concession/RR No. City/Town Province/Territory/State

Country Postal/Zip Code Telephone Numberext.

Fax Number

Email Address (required for treated seed vendor Class 12)

2. Store Physical Address InformationIs the Physical Address Information the same as the Mailing Address Information provided in section 1 (above)?

Yes No If no, please include physical address information belowPhysical AddressApt/Suite Number Street Number Street Name

Lot/Concession/RR No. City/Town Province/Territory/State

Country Postal/Zip Code Telephone Numberext.

Fax Number

Email Address

3. Business Information

Type of Application

New Licence New Licence Resulting from a Change of Ownership

Record Existing Licence # (s)

Other (specify)

Applicant Type

Corporation Individual/Sole Proprietor

Partnership Federal / Provincial / Municipal Government

Other (specify)

Business Operations (check one that applies)

General Vendor, Classes 1 to 7 pesticides (complete section 4. General Vendor Information)

Limited Vendor, Classes 5, 6 and 7 Treated Seed Vendor

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4. General Vendor Information (Complete only if you are applying for a General Vendor Licence)

Name of Certified Outlet RepresentativeLast Name First Name Middle Initial

Pesticides Vendor Certificate Number Date of Expiry (yyyy/mm/dd)

Proof of pesticides vendor certification must accompany all applications for a General Vendor Licence.

5. Supporting Information ChecklistThis is a list of all supporting information to this application and is subject to the Freedom of Information and Protection of Privacy Act (FIPPA).

Attachment Required Required if... Confidential

Application Fee: Certified Cheque, Money Order or Credit Card Yes Always Required

Proof of legal vendor business name Yes

Always Required. Examples include: • Updated Corporate Profile Report, Master Business Licence; • “Initial Notice or Notice of Change”; • Articles of Incorporation; • Extra-Provincial Licence (for out of Province companies); or • Birth Certificate (for applicants applying as an individual)

General Vendor applicant only: Copy of proof of Ontario certificate for the full time certified outlet representative

Yes Always Required

List of Sales Representatives including: Name, Email Address (if any), and Mailing Address Yes You are a treated seed vendor,

Other Attachments Please Specify

6. Signature of Applicant

In the case of a partnership or corporation, the designated official representative must sign the application.

I, the undersigned hereby declare that, to the best of my knowledge:a) The information contained herein and the information submitted in support of this application is complete and accurate in

every way and I am aware of the penalties against providing false information as per s.17(5) of the Pesticides Act.b) I am at least 18 years of agec) My certified Outlet Representative for this site location is at least 16 years of age.

(Applicable to only general vendor applicants)

Name (please print) Title

Signature Date (yyyy/mm/dd)

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Ministry of the Environment and Climate Change

Application for a Pesticide Vendor Licence

For Office Use OnlyLicence Number Billing Number

7. Payment Information

Include credit card & licence information if using this payment option.

Licence Type

General Vendor Licence ($200.00)

Limited Vendor Licence ($110.00)

Treated Seed Vendor Licence ($200.00)

Amount Enclosed ($)

Method of Payment

Certified Cheque Money Order VISA MasterCard

Credit Card Information (if paying by credit card)Name on card (please print) Credit Card Number Expiry Date (yyyy/mm/dd)

Cardholder Signature Date (yyyy/mm/dd)

This page can only be mailed or faxed to our office with the application. For the protection of your credit card information, do not submit by email.

For office use only: this page is to be detached from the application form upon the issuance of the licence