Sub Certification

Primary Certification Company *

Application Date *

Submitted By *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Name of Product *

O Primary Certification

Sub-Certification Company Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Name of Product *

Sub-Certification Company Name

List Functionality Claims from CPDA Certified Adjuvant Product label*

Category 1 (copy) *

Category 3 (copy) *

Category 1 (copy) *

Category 4 (copy) *

2. List Use-Rate at which product was tested*

Use-Rate 1 *

Use-Rate 1

Or Use-Rate range from #1 through 2

Use-Rate 2 *

Use-Rate 2

By signing this document, I hereby certify that the information is true and correct to the best of my knowledge, and further, I certify the Principal Functioning Agents in the product will perform all of the claimed functions.

Company Name *

Full Name of Submitter *

Signature *

Clear Signature

Thank you from completing this application. Please note, CPDA reserves the right to contact you with any questions or to request additional data or information needed to complete the application review and certification process. Upon submittal of this application you will receive an email confirmation of CPDA’s receipt of your application. Claims of certification can not be used on any label, electronic nor any printed marketing materials until confirmation of certification from CPDA is received by the applicant.

You will receive an electronic copy of the completed submission form. Use that copy for inclusion with the samples, labels and SDS documents to be shipped to: University of Nebraska WCREEC, Pesticide Application Technology Lab.

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