Document ID: EPA-HQ-OPP-2016-0078-0005
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2016-03-21T04:00Z

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*   Last Name* 
Company* 
Title* 
Email* 
Phone* (number only - no dashes or spaces) 
Fax (number only - no dashes or spaces) 
Address* 
City*    State/Province*    Zip* 
Industry* 

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)

                                                      OMB Control No. 2070-0188
                                                           EPA Form No. 9600-02
                                                    Approval Expires XX-XX-XXXX