Docstoc

Applicant must complete ALL sections

Document Sample
Applicant must complete ALL sections Powered By Docstoc
					                                   Application for an exemption under Regulation 7 of the
                                    Agricultural and Veterinary Products (Control of Use)
                                                      Regulations 2004.

Applicant must complete ALL sections. Please use black or blue biro. Forward completed form to:
Manager Rural Chemicals Policy, PIRSA, GPO Box 1671, Adelaide SA 5001;
Fax: 08 8226 1844; E-mail PIRSA.Ruralchemicals@state.sa.gov.au

1. PERSONAL DETAILS

   Name of applicant: _________________________             Name of Company: ________________________

   Address of applicant:                                    Address of Company:

   Street: ___________________________________              Street: __________________________________

   Town: ___________________________________                Town:___________________________________

   State: ____________ Post Code: _____________             State: ____________ Post Code: _____________

   Postal address:____________________________              Postal address: ___________________________

    ________________________________________                ________________________________________

   Phone (business hours): ____________________             Mobile: __________________________________

   E-mail: __________________________________               Fax: ____________________________________



2. QUALITY ASSURANCE SCHEME

   Name of Quality Assurance Scheme: ____________________________________________________

    __________________________________________________________________________________

   Name of organisation administering the Scheme: ___________________________________________

    __________________________________________________________________________________

   Contact phone number for administering organisation: _______________________________________

    __________________________________________________________________________________



   Tick any of the following activities that are required by the Scheme.

       Keeping of records for chemical treatments of crops or post-harvest produce, including chemical
       used, treatment date, application rate and method.

       Identification or recording of treated crops or produce.

       Recording the date of harvest of treated crops.

        Recording the destination of harvested crops.

        Annual audits by an external auditor.



                                        RURAL CHEMICALS PROGRAM                              September 2004
                                 14th Floor, 25 Grenfell Street, Adelaide SA 5000
                                        GPO Box 1671 Adelaide SA 5001
                               Telephone (08) 8226 0549 Facsimile (08) 8226 1844
                                   International Code +618 www.pir.sa.gov.au
                                   Application for an exemption under Regulation 7 of the
                                    Agricultural and Veterinary Products (Control of Use)
                                                      Regulations 2004.

  Complete sections 3 and 4 for each crop requiring exemption for this QA
  Scheme. For each additional crop or chemical, photocopy this page and repeat
  sections 3 and 4 and attach to application.

3. CROP

  Name of crop requiring exemption: ______________________________________________________



4. CHEMICAL DETAILS

  Full Name of Product to be used:________________________________________________________

  Active Constituents and Concentrations: __________________________________________________

   __________________________________________________________________________________

   __________________________________________________________________________________

  Manufacturer of Product: ______________________________________________________________

  Name of Pests to be targeted: __________________________________________________________

   __________________________________________________________________________________

   __________________________________________________________________________________

  *Justification for Use: (eg no registered products/ resistance to registered products) ____________________

   ____________________________________________________________________________________________

   ____________________________________________________________________________________________

   __________________________________________________________________________________

   __________________________________________________________________________________

  Method of application: ________________________________________________________________

   __________________________________________________________________________________

  Stage of Crop at time of treatment: ______________________________________________________

  Rate of application:___________________________________________________________________

  Frequency of application: ______________________________________________________________

   __________________________________________________________________________________

  Withholding period:___________________________________________________________________




                                       RURAL CHEMICALS PROGRAM                                  September 2004
                                14th Floor, 25 Grenfell Street, Adelaide SA 5000
                                       GPO Box 1671 Adelaide SA 5001
                              Telephone (08) 8226 0549 Facsimile (08) 8226 1844
                                  International Code +618 www.pir.sa.gov.au
                                       Application for an exemption under Regulation 7 of the
                                        Agricultural and Veterinary Products (Control of Use)
                                                          Regulations 2004.

   *Justification for use. If applying for an exemption for a major crop (as listed below), a simple justification
   is required initially, followed by a more detailed justification to be supplied within 6 months. This should
   include:
              •   Total area of the particular crop grown in South Australia; and
              •   Total area of affected crop for each pest; and
              •   Details of damage caused by each pest; and
              •   Detailed explanation of why existing products registered for the particular crop are not
                  effective or suitable.
   Major crops for the purposes of this exemption are:
   Citrus (oranges, lemons); Grapes; Onions; Pome fruit (apples, pears); Potatoes. All other crops are
   minor crops.



5. RELEVANT INDUSTRY CONTACT DETAILS if relevant (for notification to other crop growers):

   Name of industry organisation: _________________________________________________________

    __________________________________________________________________________________

   Name of contact: ____________________________________________________________________

   Address of organisation: Street:_________________________________________________________

   Town: ___________________________________                   State: ___________ Post Code: ______________

   Phone (business hours): ____________________                Mobile: __________________________________

   E-mail: __________________________________                  Fax: ____________________________________




6. DECLARATION

   I ____________________________________declare that the information I have provided above is to

   the best of my knowledge true and correct. I understand that Primary Industries and Resources SA

   (PIRSA) has the right to refuse granting this exemption and may revoke an exemption at any time.



   Signed: __________________________________                  Date: ___________________________________


   Privacy Statement: The information on this application form will be stored and used by Primary
   Industries and Resources SA (PIRSA) for the purposes of administering the Agricultural and Veterinary
   Products (Control of Use) Act 2002 (the Act). You have the right of access to this information by
   contacting PIRSA. This information may be disclosed to another government organisation for the
   purpose of administering or enforcing the Act or a relevant Act.


                                           RURAL CHEMICALS PROGRAM                                 September 2004
                                    14th Floor, 25 Grenfell Street, Adelaide SA 5000
                                           GPO Box 1671 Adelaide SA 5001
                                  Telephone (08) 8226 0549 Facsimile (08) 8226 1844
                                      International Code +618 www.pir.sa.gov.au

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:6
posted:3/14/2010
language:English
pages:3
Description: Applicant must complete ALL sections