Aerial Application Request Form
Please Enter Your Trading Name
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Please Enter Your Name
*
Please Enter Your Email Adress
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Please Enter Your Phone Number
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Please Enter Your Agronimists Name And Phone Number - If Applicable
Enter Your Agronomists Email Adress - If Applicable
example@example.com
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Do You Have A Recomendation From An Agronimist? If Yes Please Provide The Recomendation In Full In The Next Section
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Yes
No
Total Hectares Requested
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Please Attach A Copy Of Your Recomedation And Maps
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Prefered Application Date
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Airstrip To Be Used
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Do you confirm all the Details and Maps of this Recomendation Are Correct?
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Yes
No
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Type Of Application
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Spraying (Fungicide/Insecticide/Herbicide)
Fertilising (Urea/SuperPhosphate)
Baiting (Slugs/Mice
Other
Preferred Application Date
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Airstrip To Be Used
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Wind Dirrection Required
Water Rate / Ha
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10L/HA
20L/HA
30L/HA
40L/HA
N/A
Other
Total Hectares To Be Treated
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Will All Fields Be Treated With The Same Products and Rate?
Yes
No
Fields To Be Treated
Field Name
Hectares
Product
Product Rate
1
2
4
4
5
6
7
8
9
10
Product Details
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Product Name
Product Type
Product Rate Per Hectare
Total Product Required For Job
Supplied By
1
Fungicide
Insecticide
Herbicide
Adjuvant/Wetter
Fertiliser
Bait
Other
Client
Agronomist
2
Fungicide
Insecticide
Herbicide
Adjuvant/Wetter
Fertiliser
Bait
Other
Client
Agronomist
3
Fungicide
Insecticide
Herbicide
Adjuvant/Wetter
Fertiliser
Bait
Other
Client
Agronomist
4
Fungicide
Insecticide
Herbicide
Adjuvant/Wetter
Fertiliser
Bait
Other
Client
Agronomist
5
Fungicide
Insecticide
Herbicide
Adjuvant/Wetter
Fertiliser
Bait
Other
Client
Agronomist
6
Fungicide
Insecticide
Herbicide
Adjuvant/Wetter
Fertiliser
Bait
Other
Client
Agronomist
7
Fungicide
Insecticide
Herbicide
Adjuvant/Wetter
Fertiliser
Bait
Other
Client
Agronomist
8
Fungicide
Insecticide
Herbicide
Adjuvant/Wetter
Fertiliser
Bait
Other
Client
Agronomist
9
Fungicide
Insecticide
Herbicide
Adjuvant/Wetter
Fertiliser
Bait
Other
Client
Agronomist
10
Fungicide
Insecticide
Herbicide
Adjuvant/Wetter
Fertiliser
Bait
Other
Client
Agronomist
Please Attach A Copy Of A Map (Please Mark All Powerlines)
*
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See Below An Example Of A Well Marked Map
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Have You Provided A Map?
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Yes
No
Do Any Of The Areas To Be Treated Have Powerlines?
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Yes
No
Are There Any Susceptible Crops? If Yes Please Describe In Comments (Relevant for Herbicide Applications)
Yes
No
Is There Any Bees, Orgainc Farms Or Aquatic Farms? (If Yes Or Other, Please describe in the comments section at the end)
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Yes
No
Other
Is There Any Dwellings withing 150M of the application Area?
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Yes
No
Have You Notified Your Neigbours Of The Application?
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Yes
No
Is The Product Requested Registered On Label for Aerial Application?
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Yes
No
Comments
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Airstrip Use and Chemical Drop Off
Please Speak with Adam on 0407 293 218 Or Alex on 0409 339 970 in regards to the Airstrip to be Used where to deliver chemical.
I Agree to Hazair's Terms And Conditions Of Aerial Application
*
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