Owner name *

First Name

Last Name

Property Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Weeds targeted *

Blackberry

Paterson's Curse

Chilean Needle Grass

Serrated Tussock

St John's Wort

Other (provide description in message window below)

Density of Infestation *

Individual plants

Spot infestations

Broad acre infestation (enter approximate hectares in message window below)

Purchase date *

MM

DD

YYYY

Application method

Hand spray/backpack

Trailer unit

Other (provide details in message window below)