United
States
FORM
APPROVED
Environmental
Protection
Agency
OMB
NO.
2070­
0078
Washington,
DC
20460
Application
for
Registration
of
Pesticide­
Producing
and
Device­
Producing
Establishments
Section
7,
Federal
Insecticide,
Fungicide,
and
Rodenticide
Act,
(
7
U.
S.
C.
136e)

Note:
Read
all
instructions
before
completing.

1.
Company
Name
11.
EPA
Company
Number
2.
Company
Name
(
if
different
from
1)
12.
Company
D
&
B
No.

Company
Headquarters
Location
13.
Enter
Appropriate
Ownership
code
1
­
Individual
2
­
Partnership
3
­
Cooperative
Association
4
­
Corporation
5
­
Other
________________________________________________
3.
Street
Address
4.
City
5.
State
or
County
6.
Zip
Code
Company
Headquarters
Mailing
Address
(
If
identical
to
above,
write
SAME)
14.
State
or
Country
of
Incorporation
7.
Street
or
PO
Box
Address
15.
Date
of
Incorporation
(
Month,
Day,
Year)

8.
City
9.
State
or
Country
10.
Zip
Code
NAME,
SITE
LOCATION,
and
MAILING
ADDRESS
of
EACH
NEW
PRODUCING
ESTABLISHMENT
16.
Establishment
Name
EPA
Est.
No.
(
EPA
use
only)

17.
Establishment
Site
Address
18.
City
19.
State
or
Country
20.
Zip
Code
21.
Establishment
Mailing
Address
22.
City
23.
State
or
Country
24.
Zip
Code
25.
NAICS
Code.
26.
D
&
B
No.

16.
Establishment
Name
EPA
Est.
No.
(
EPA
use
only)

17.
Establishment
Site
Address
18.
City
19.
State
or
Country
20.
Zip
Code
21.
Establishment
Mailing
Address
22.
City
23.
State
or
Country
24.
Zip
Code
25.
NAICS
Code.
26.
D
&
B
No.

16.
Establishment
Name
EPA
Est.
No.
(
EPA
use
only)

17.
Establishment
Site
Address
18.
City
19.
State
or
Country
20.
Zip
Code
21.
Establishment
Mailing
Address
22.
City
23.
State
or
Country
24.
Zip
Code
25.
NAICS
Code.
26.
D
&
B
No.

EPA
USE
27.
NAME
of
Company
Officer
28.
Telephone
Number
EPA
Received
date
Postmark
date
29.
E­
mail
Address
(
Optional)
30.
FAX
Number
(
Optional)
USE
Signature
31.
TITLE
of
Company
Officer
32.
Date
Signed
(
Month,
Day,
Year)
ONLY
Region
33.
SIGNATURE
of
Company
Officer
Review
Date
EPA
Form
3540­
8
(
Rev.
04­
01)
Previous
editions
are
obsolete.
THIS
IS
PAGE
_________
OF
________
