WS 18 Control Materials Sales Record

Clear Form
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 4 minutes 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES

CONTROL MATERIAL SALES RECORD
2. NAME OF WS REPRESENTATIVE

1. SELECT ONE:
A. MATERIALS SOLD AND TREATMENT SUPERVISED
B. MATERIALS SOLD BUT NOT SUPERVISED
3. DATE

5. LAND STATUS

OMB Approved
0579-0335
EXP: XX/XXXX

4. COUNTY

6. SPECIES INVOLVED

PRIVATE

STATE

FEDERAL

OTHER

7. DAMAGE TO

8. ACRES TREATED

9. DOLLAR LOSS

10. 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.
11. APPLICATOR'S NAME (print)

14. BUYER'S SIGNATURE

12. ADDRESS

15. CERTIFIED PESTICIDE APPLICATOR NUMBER (all restricted use pesticide sales)

13. TELEPHONE NUMBER (including area code)

16. MAKE CHECK PAYABLE TO:

WS FORM 18
APR 2017

Ensure the Applicator receives a copy of the Privacy Act Notice

PRIVACY ACT NOTICE
5 U.S.C. 552a(e)(3) requires that each agency that maintains a system of records provide each individual from whom the agency solicits information with the following information.
AUTHORITY FOR REQUESTING INFORMATION
7 U.S.C. 8351 to 8353, and 16 U.S.C. 667, authorizes officers, agents, and employees of the United States Department of Agriculture (USDA), Animal and Plant Health Inspection Service (APHIS),
Wildlife Services (WS) to conduct a program of wildlife services and to enter into agreements with States, local jurisdictions, individuals, and public and private agencies, organizations, and institutions for
the purpose of conducting such services.
NATURE OF YOUR DISCLOSURE OF INFORMATION
Disclosure of information solicited by USDA, APHIS, Wildlife Services is voluntary.
PRINCIPLE PURPOSE FOR WHICH THE INFORMATION IS SOLICITED
Information is solicited from you for the purpose of executing and implementing agreements for control of wildlife damage.
ROUTINE USES WHICH MAY BE MADE OF THE INFORMATION
(1) To cooperative Federal, State, Tribal, and local government officials, employees, or contractors and other parties as necessary to carry out the program; and other parties engaged to assist in
administering the program. Such contractors and other parties will be bound by the nondisclosure provisions of the Privacy Act. This routine use assists the agency in carrying out the program, and thus is
compatible with the purpose for which the records are created and maintained;
(2) To the appropriate agency, whether Federal, State, local, Tribal, or foreign, charged with responsibility of investigating or prosecuting a violation of law or of enforcing, implementing, or complying
with a statute, rule, regulation, or order issued pursuant thereto, of any record within this system when information available indicates a violation or potential violation of law, whether civil, criminal, or
regulatory in nature, and either arising by general statute or particular program statute, or by rule, regulation, or court order issued pursuant thereto;
(3) To the Department of Justice when the agency, or any component thereof, or any employee of the agency in his or her official capacity, or any employee of the agency in his or her individual capacity
where the Department of Justice has agreed to represent the employee, or the United States, in litigation, where the agency determines that litigation is likely to affect the agency or any of its components,
is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice is deemed by the agency to be relevant and necessary to the litigation; provided,
however, that in each case, the agency determines that disclosure of the records to the Department of Justice is a use of the information contained in the records that is compatible with the purpose for
which the records were collected;
(4) For use in a proceeding before a court or adjudicative body before which the agency is authorized to appear, when the agency, or any component thereof, or any employee of the agency in his or her
official capacity, or any employee of the agency in his or her individual capacity where the agency has agreed to represent the employee, or the United States, where the agency determines that litigation
is likely to affect the agency or any of its components, is a party to litigation or has an interest in such litigation, and the agency determines that use of such records is relevant and necessary to the
litigation; provided, however, that in each case, the agency determines that disclosure of the records to the court is a use of the information contained in the records that is compatible with the purpose for
which the records were collected;
(5) To appropriate agencies, entities, and persons when the agency suspects or has confirmed that the security or confidentiality of information in the system of records has been compromised; the
agency has determined that as a result of the suspected or confirmed compromise, there is a risk of harm to economic or property interests, a risk of identity theft or fraud, or a risk of harm to the security
of integrity of this system or other systems or programs (whether maintained by the agency or another agency or entity) that rely upon the compromised information; and the disclosure made to such
agencies, entities, and persons is reasonably necessary to assist in connection with the agency’s efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such
harm;
(6) To USDA contractors, partner agency employee or contractors, or private industry employed to identify patterns, trends, or anomalies indicative of fraud, waste, or abuse;
(7) To land management agencies, such as the Bureau of Land Management and the U.S. Fish and Wildlife Service, relating to wildlife damage on grazing allotments;
(8) To consumer reporting agencies in accordance with 31 U.S.C. 3711(e);
(9) To Federal, State, Tribal, and local regulatory agencies and their employees and contractors who collaborate with Wildlife Services in implementation of, or agencies that regulate, wildlife
management projects or programs, or who have an interest in, or regulate, animal or public health, or national security;
(10) To Federal or State Government-level representatives of the U.S. Environmental Protection Agency, in compliance with the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) mandate in
7 U.S.C. 136(f, and i thru l), of the location on a cooperator’s property where certain regulated pesticide devices are deployed or regulated pesticides are applied; and
(11) To the National Archives and Records Administration (NARA) or to the General Services Administration for records management inspections conducted under 44 U.S.C. 2904 and 2906.
EFFECTS OF FAILURE TO FURNISH INFORMATION
Failure to provide the solicited information will not subject you to penalties or adverse consequences.