Information Provider Profile Form for Initial Electronic Pesticide Regulatory System (e-PRS) Enrolment

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This form must be completed and must accompany every Primary Officer request for initial Electronic Pesticide Regulatory System Secure Web Portal (e-PRS SWP) enrolment submitted to the Pest Management Regulatory Agency (PMRA).

A Primary Officer wishing to make changes to an established Information Provider Profile should contact the PMRA to discuss the changes and to seek advice as to what documentation will be required to be submitted to support the change request.

Please note: Steps 1 to 4 must be completed.

Step 1

Business Name of the Information Provider as per the
.
Please provide full name instead of abbreviations, unless they form part of the legal name of the company.

Step 2

Primary Officer Mailing Address and Contact Information.
Please provide the mailing address of the Primary Officer and ensure the address is complete and capable of receiving postal mail delivery. In addition, please provide the Primary Officer contact information.
Note: the Primary Officer must be an officer or employee of the Information Provider.
  • Mailing Address:
  • City/Town:
  • Province/State:
  • Country:
  • Postal Code/ZIP:
Primary Officer.
The contact identified must be the same as the person who signed the Terms and Conditions of Use Agreement.
  • Name:
  • Title:
  • Phone:
  • Fax:
  • E-mail:
  • Signature of Primary Officer:

Step 3

Please provide the answers to all 4 of the shared secrets below. Remember your answers as they will be required to activate your e-PRS SWP account, when we send you your activation key.

  • What is your favourite type of food?
  • What is your favourite type of drink?
  • What is your favourite colour?
  • What is your favourite sport?

Step 4

Please indicate with an "X" all of the roles that apply to this Information Provider:

Information Provider Role
Brief Description
X = Yes
Applicant and Registrant
The Information Provider holds or intends to hold registrations.
 
Representative
The Information Provider intends to represent and transact on behalf of an applicant and registrant.
 
Third Party Information Provider
The Information Provider intends to provide only third party information (e.g., statement of product specification) to support applications made by others.
 

All information providers who indicated in Step 4 that they hold or intend to hold registrations (e.g., applicant/registrant) must complete the rest of the form.

Step 5

Applicant/Registrant Business Address and Contact Information.
Please ensure the business address provided is complete and capable of receiving postal mail delivery. This would typically be the Headquarters address. In addition, please provide the contact information for the principal contact located
at this
address.
  • Same info as step 2
  • Mailing Address:
  • City/Town:
  • Province/State:
  • Country:
  • Postal Code/ZIP:
Principal contact located at this address
  • Name:
  • Title:
  • Phone:
  • Fax:
  • E-mail:

Step 6

Regulatory Mailing Address
for the Applicant/Registrant identified in Step 5
  • Same info as step 2 or
  • Same info as step 5
  • Business Name (Full name - no abbreviations):
  • Mailing Address:
  • City/Town:
  • Province:
  • Canada
  • Postal Code:
Principal contact located at this address
  • Name:
  • Title:
  • Phone:
  • Fax:
  • E-mail:

If you require assistance in completing this form or with any other aspects of preparing the enrolment request, please contact the Pest Management Information Service.

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