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Sample form Agricultural Chemical Product on Agricultural Produce

Permission to use an Agricultural Chemical Product on Agricultural Produce issued under the Agricultural and Veterinary Chemicals (Control of Use) Act 1992

Please complete ALL sections and write in CAPITAL LETTERS

1. Commodity (Description)

2. Names/types of chemical products to be used ¹

a.

b.

c.

3. Name of the person(s) or company undertaking the use of the chemical products

4. Name of address of the owner of the agricultural produce

Name:
Street/Road/Property
Town/Suburb	State:	Postcode
Signed (owner)		Date:

5. Period for which this authority is valid:²

¹ This can be a particular chemical product, or a group of chemicals.

² This can be any length of time the owner wishes to approve.