2415.03 Attachment E

ATTACHMENT E
PESP Membership Application
Note: The form below is a reproduction of a form that was developed for online use.
Paperwork Reduction Act Notice: The paperwork burden for the PESP Membership Application form is
estimated to average 2 hours per response, including time for reading the instructions, gathering and
maintaining information, and completing the form. Responses to this collection of information are
necessary in order to participate in the voluntary program. 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. Send comments regarding the burden estimate or any other aspect of this collection
of information, including suggestions for reducing the burden, to the Director, Collection Strategies
Division (2822T), U.S. Environmental Protection Agency, Washington, DC 20460; and to OMB, addressed
to Desk Officer for EPA, via email to oira_submission@omb.eop.gov. Do not send completed forms to
these addresses.
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*

Company*

Title*

Email*

Primary

--None--

Last Name*

Phone* (number only - no dashes or spaces)

Fax (number only - no dashes or spaces)

Address*
City*

Industry*

State/Province*

Zip*

--None--

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)

Submit Application

OMB Control No. 2070-0188
EPA Form No. 9600-02
Approval Expires 11-30-2016