NHEC's Herbicide Application Opt-Out Form

Please note that this form is valid for the calendar year. You will need to complete a new form each year.

Date(Required)

MMMM123456789101112

DDDD12345678910111213141516171819202122232425262728293031

YYYYYYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Did you receive notification from NHEC regarding the herbicide application program?(Required)

Yes

No

Member Name(Required)

First Last

Member Account #(Required)

Meter #(Required)

Service Location(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mailing Address (if different from Service location)(Required)

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Town Parcel Number

Property Details

Consent(Required)

I am opting-out of herbicide treatment for the calendar year. I understand that my opt-out status must be renewed each year by submitting a new form.

Δ