WS Form 18 Control Materials Sales Record

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 0579-0335. The time required to complete this information collection is estimated to average .063 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.						OMB Approved 0579-0335 EXP XX/XXXX
United States Department of Agriculture Animal and plant health inspection service Wildlife services Control material sales record			“X” one
				materials sold and treatment supervised
				materials sold but not supervised
name of ws representative			date		county
Land status Private State Federal Other			species involved
damage to			acres treated		dollar loss
material sold
kind	epa regulation number		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)
PHONE NUMBER (Include Area Code)		MAKE CHECK PAYABLE TO:

WS FORM 18

JAN 2011