JPF DISTRIBUTORS, LLC, Animal Control, BobbeX, Bird Bangers

WILDLIFE
CONTROL STATEMENT

(If you have any questions before placing the order
please call us at 1-800-582-8843)

	1. Print Out THIS PAGE
	2. Completely Fill Out Wildlife Control Statement
	3. Sign Wildlife Control Statement
	4. Fax Your Wildlife Control Statement to 1-800-582-8843
	5. A JPF Customer Service Representative will Call You to Take Your Order.

WILDLIFE CONTROL STATEMENT

PLEASE FILL OUT COMPLETELY, SIGN THIS FORM
AND RETURN IT TO US FOR OUR RECORDS.

WILDLIFE CONTROL STATEMENT
MUST BE SIGNED AND ON FILE BEFORE LAUNCHERS,
NOISEMAKERS, OR PROPELLANTS CAN BE SHIPPED.

YOUR ORDER WILL NOT BE SHIPPED WITHOUT A
COMPLETED FORM ON FILE.

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Your Name:________________________________________________________________
.

Company Name:________________________________________________________
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Address:________________________________________________________________
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City:_______________________________State________Zip______________________
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Phone Number:_____________________________ FAX #_______________________
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Drivers License Number_____________________________________ STATE_______
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USA Citizen (circle) Yes No Place of Birth________________________
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DOB_____________________
..

.SSN #____________________________ or Company Tax#:_____________________

1. CERTIFICATION OF BUYER - An untruthful answer may subject you to criminal prosecution. Each question must be answered Yes or No

a. Are you a fugitive from justice?_________

b. Are you an unlawful user of, or are you addicted to, marijuana or any depressant, stimulant or narcotic drug, or any other controlled substance?_________

c. Have you or the business entity ever been convicted in any court of a felony, or any other crime, for which the judge could have imprisoned you for more than one year, even if you received a shorter sentence including probation? Definition - an indictment information, or conviction in any Federal, State, local or foreign court._________

d. Are you or the business entity under indictment for information in any court for felony, or any other crime , for which the judge could imprison you for more than one year? An information is a formal accusation of a crime by a prosecutor._________

e. Have you ever been adjudicated mentally defective (which includes having been adjudicated incompetent to manage you own affairs) or have you ever been committed to a mental institution?_________

f. Have you ever been discharged from the Armed Forces under dishonorable conditions.________

g. Have you ever renounced your United State citizenship?_________

h. Are you an alien in the United States? An alien means any person who is not a citizen or national of the United States, except that for the purposes of this form, an alien in the U.S. is not prohibited from shipping, transporting, receiving or possessing explosive materials if the alien is a lawful permanent resident as defined under Section 18 U.S.C.842(d)(7);(i)(5)_______

2. If you are an alien in the United States, do you fall within the exception set forth in item 1 h above?_________

3. If you are not a citizen of the United States, what is you INS-issued alien or admission number?____________

PEST I WILL DETER: (Type of Birds or Wildlife)	INVESTMENT I AM PROTECTING: (Kind of Crop, Structure or Area)
_________________________________ _________________________________	______________________________ ______________________________

I UNDERSTAND AND AGREE THAT LAUNCHERS, ALL NOISEMAKERS
AND PROPELLANT PURCHASED FROM JPF DISTRIBUTORS,
LLC MUST BE USED OR RESOLD FOR AGRICULTURE OR ANIMAL
DAMAGE CONTROL PURPOSES ONLY AND THESE ITEMS WILL NOT
BE SOLD OR USED FOR ANY OTHER PURPOSE.

THIS CERTIFICATION APPLIES TO THIS AND ALL SUBSEQUENT ORDERS.

The purpose of this Statement is to identify the person(s) responsible for safe
use of wildlife pest control products purchased from JPF Distributors, LLC and
to warn those persons that launchers, propellant and Noisemakers are dangerous and
must be used according to instructions and with caution.

I understand that:

1. Hand Held Launchers, Noisemakers, and Launcher Propellants must be used
for wildlife pest control ONLY.
2. Instructions for proper use come with each product. In these instructions,
JPF Distributors, LLC and Importer recommend the use of ear and eye
protection with all Noisemakers. These protection devices are available from
JPF Distributors, LLC.
3. JPF Distributors, LLC and Importer shall not be held responsible for any
injury resulting from the use or handling of these devices whether used in
accordance with directions or not.
4. The buyer and/or user agree(s) to secure local and state use permits
if required.
5. The buyer and/or user of explosive products must be 21 years of age
or older.
6. The buyer and/or user hereby accept(s) these products subject to all
the terms hereof.
7. Please be advised that all JPF Distributors, LLC sales records Pertaining
to Noisemakers and related shipping documents are available to, and are
subject to, examination by the government agencies responsible for
all explosive hazardous materials.

I hereby certify that I have a bona fide agricultural or bird/animal control
application for these pest control devices and certify that they will be
used ONLY for bird/animal control purposes.

I further understand that any other use of these items is
STRICTLY PROHIBITED BY LAW.

I Further Understand that by my Signature I am Certifying, under penalty of perjury,
that all statements given to me in the Wildlife Control Statement are factual and true.

I am interested in the following Products;

		Standard 12 Gauge Noisemakers
		15 mm Noisemakers
		BobbeX Turf and Plant Spray

PLEASE SIGN THIS FORM AND FAX IT TO US FOR OUR RECORDS.
1-800-582-8843

I have read and understand all of the above statements.

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Signature:___________________________________Date:______________

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Please print name:________________________________ Title:__________________
.

YOUR ORDER WILL NOT BE SHIPPED WITHOUT A
COMPLETED FORM ON FILE.

THIS FORM MAY BE FAXED TO 1-800-582-8843
OR MAILED TO THE ADDRESS BELOW.

Thank you for your cooperation,

JPF Distributors, LLC

If you have any Questions Please contact us at

1-800-582-8843

JPF DISTRIBUTORS, LLC,
385 Main Street South
Suite 404-184
Southbury, CT 06488

1- 800-582-8843

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