WS Form 18 Control Material Sales

OMB No. 0579-XXXX
"X" ONE

US DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES

MATERIALS SOLD AND TREATMENT SUPERVISED
MATERIALS SOLD BUT NOT SUPERVISED

CONTROL MATERIAL SALES RECORD
NAME OF WS REPRESENTATIVE

DATE

LAND STATUS

SPECIES INVOLVED

PRIVATE

STATE

FEDERAL

COUNTY

OTHER
ACRES TREATED

DAMAGE TO

DOLLAR LOSS
$

MATERIAL SOLD
KIND

EPA REG. NO.

QUANTITY

COST

$

$
$

I have been instructed in the specific use of the requested material and agree to use it in accordance with procedures recommended by Wildlife Services, USDA
APPLICATOR'S NAME (Print)

BUYER'S SIGNATURE

ADDRESS (Street, P.O. Box No. City, State, and Zip Code)

CERTIFIED PESTICIDE APPLICATOR NUMBER
(All restricted use pesticide sales)

MAKE CHECK PAYABLE TO:
PHONE NUMBER (Include Area Code)
WS 18
MAY 2002

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0579-XXXX. The time required to complete this information collection is estimated to average .063 minutes/hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.