Small Business Certification Examples

A workgroup comprising representatives of registrant companies and trade associations designed a form for assisting pesticide registrants when they submit small business waiver requests under the Pesticide Registration Improvement Act. Use of the form is voluntary and information submitted using the forms will be accepted by the Agency. Other formats that meet the requirements of the statute will be acceptable to the Agency as well.

Voluntary Small Business Waiver Form

An Example of a Certification for Small Business

Section 1: Business Identification

• Name of the applicant
• Company number assigned by OPP to the applicant
• Official mailing address under FIFRA
• Name of the contact person for the waiver or fee reduction request
• Phone number, fax number, and e-mail for the contact person

Section 2: Small Business Criteria

A) Global Gross Revenue from Pesticides

1. Do you have any subsidiaries? Please include any indirect subsidiaries (subsidiaries of subsidiaries or other subsidiaries of a parent entity) as well. 
2. Do you have any parent entities? Please provide information regarding the ownership of your ultimate parent (including the percentage ownership/membership interest of each stakeholder).
   1. If you do not have a parent entity, please provide information on the ownership of the applicant and the percentage ownership/membership interest of each stakeholder.
3. Do any stakeholders with a controlling interest in the applicant or any parent entity also directly or indirectly control or have the ability to directly or indirectly control any other entity?
4. Which affiliates, if any, have global gross revenue from pesticides?
5. Including affiliates, what is your global gross revenue from pesticides, averaged over the applicable three year period?
6. If you are distinguishing global gross revenue from pesticides from other gross revenue, please explain how you differentiated and calculated global gross revenue from pesticides alone.

B) Employee Threshold

1. Do you employ 500 or fewer employees? What is the number of employees?

Section 3: Certification Statement

“I, [insert name of undersigned], the [insert title] of [insert name of applicant], am authorized and have personal knowledge sufficient to make this certification on behalf of [insert name of applicant]. I hereby certify under penalty of perjury that the documentation submitted in connection with [insert name of applicant]’s this fee waiver request is true, complete, and correct in all material respects.”

Applicant’s Name
Applicant Signature
Title
Date