21—45.28 (206) Emergency single purchase/single use of restricted pesticide. The department shall issue a temporary certificate to private applicators for a single purchase/single use of restricted pesticides in situations declared to be an emergency by the department, upon receipt of the following completed and signed affidavit.
21—45.28(206) EMERGENCY USE OF A RESTRICTED USE
PESTICIDE BY A PRIVATE APPLICATOR
Emergency Single Purchase/Single Use of Restricted Pesticide—Affidavit.
The Label which I have read, indicates:
Brand name of pesticide:  	
Federal Registration Number:  	
Name of Active Ingredient(s):  	
Percentage of Active Ingredient(s):  	
If the pesticide product is to be mixed with a carrier, show the amount of pesticide product per gallon
of tank mix:
	
Application rate per acre:  	
Name pest to be controlled:  	
At what stage of development is the pest most easily controlled:
	
State degree of hazard (signal word):  	
Describe safety equipment required:  	
What is the recommended antidote for this product:  	
List environmental precaution shown on label:  	
Length of time until re-entry, if given:  	
Preharvest interval days required:  	
Describe method of container disposal:  	
I wish to make application of this pesticide on (date) 	
and I hereby swear under penalty of perjury that I understand the above label information and warnings.
_________________________________________
(name of private applicator)
This rule is intended to implement Iowa Code sections 206.4 and 206.5.