NJDEP Compliance and Enforcement - Pesticide Product Registration Form

Governor Phil Murphy • Lt. Governor Tahesha Way

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NJ Department of Environmental Protection

Bureau of Pesticide Control

Pesticide Licensing, Permits and Registration

PO Box 420 – MC 401-04A

Trenton, NJ 08625-0420

www.pcpnj.org

Application for the Initial Registration of a Pesticide Product

NOTE: ALSTAR system subscribers do not need to submit this application!

Instructions

Use this form to register pesticide products in NJ for the first time. Do not use this form to renew products.
Be sure to enter all the information required for the Registrant (the entity whose name appears on the product label) & the Billing Party (the entity who will be responsible for the registration paperwork, including paying any registration fees). Each unique combination of Registrant & Billing Party equates to a NJDEP Program Interest ID. If the combination of Registrant & Billing Party entered below already has a NJDEP Program Interest ID, please be sure to enter it in the space provided.
You can register up to 10 products using this form. If you have more than 10 products to register, complete another, separate form. Only products that have the same Registrant & Billing Party can be grouped on the same form.
For each product listed, you will have to email the NJDEP a copy of the finished product label, in PDF format. The email address to send the labels to is: pesticideproduct@dep.nj.gov. The subject line of the email must be in the format 'Initial Pesticide Registration Submitted MM/DD/YYYY for [Registrant Name]'.
You will be billed for the required registration fee for initial product registration after the products are downloaded into the NJDEP product registration system. Once billed, you will be able to pay for them by using the NJDEP Online Pesticide Product Registration service.

Information on Product Registrant (the company name that appears on the product label)

Registrant Name:
Registrant Phone # (including area code and extension): Ext:

Registrant Physical Address

Address Line 1 (No PO Boxes):
Address Line 2 (optional):
City:
State or Country:

Zip or Mail Code:
If in New Jersey, County:

Registrant Mail Address

Address Line 1: (required)
Address Line 2: (optional)
City:
State or Country:

Zip or Mail Code:
If in New Jersey, County:

Information on Billing Party (the entity responsible for registration paperwork, including payments)

Billing Party Name:
Contact Person (first name last name):

Contact Phone # (including area code & extension): Ext:

Contact Email Address:

Billing Party Mail Address

Address Line 1:
Address Line 2: (optional)
City:
State or Country:

Zip or Mail Code:
If in New Jersey, County:

If the combination of Registrant & Billing Party above already has an NJDEP Program Interest ID, enter below:

Program Interest ID (example: 001234) :

Does the Registrant have an ALSTAR subscription?

Yes No

New Pesticide Products to be Registered (must enter at least 1 product). Please enter Brand Name & any Colors/Fragrances in Upper Case.

Note: If the only difference in the name of a product is a color or a fragrance, then that product is considered to be just one brand name. Enter the brand name in the ‘Brand Name’ field, with ‘various colors’ or ‘various fragrances’, in parenthesis, instead of the color or fragrance. Then enter the colors or fragrances in the ‘Color/Fragrance’ field.

1. EPA Registration Number:
(Format EPA Reg # as 123456-12345 or 123456-12345-123456. Use leading zeroes when necessary, for example: 000456-00345)

USEPA Restricted Use? Yes No

Brand Name: