1 Name and Address of Customer 2 Date Pesticide(s) or Device(s 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with the 'Name and Address of Customer' section. Enter the full name and address of the customer accurately, ensuring all details are correct for effective communication.
3. Next, move to the 'Date' field. Input the date when the pesticide(s) or device(s) were used. This is crucial for record-keeping and compliance.
4. Proceed to fill in the 'Pesticide(s) Used and EPA Reg. #(s)' section. List each pesticide used along with its corresponding EPA registration number.
5. In the 'Device(s) Used' field, specify any devices utilized during application, ensuring clarity on what was employed.
6. Complete the 'Mixing Rate' section by detailing how much pesticide was mixed per device, which is essential for accurate reporting.
7. Finally, ensure you fill out any additional fields such as target pest and service address if different from the customer's address.

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