Application Record Keeping Form - DuPont USA

1 Application Record Keeping FormCertified Applicator Name: State Certification # of Applicator: Applicator Name (if different from Certified Applicator): Applicator Name (if different from Certified Applicator): Provider (be sure to retain proof of completion): Date Completed (MM/DD/YY): REQUIRED DICAMBA APPLICATOR TRAININGName and Date of the Sensitive Crop Registry Consulted: AND/ORDate Neighboring Fields Were Surveyed for Susceptible Crops: Retain receipt of each purchase for each Application . Retain copy of product label. (Current label found at: )Approved Dicamba Product Name & EPA Reg.

2 #: To Be Applied To: Corn Cotton Soybeans Other Location of Application : Buffer Distance Calculation: Size of Treated Area: Total Amount Applied: Check to Confirm Tank Is Cleaned Prior to Using: (notes) Manufacturer/Brand: Type: Orifice Size: Operating Pressure: SUSCEPTIBLE CROP AWARENESSNOZZLEINFORMATIONAPPLICATIONTIM INGSPRAYINGINFORMATIONPREAPPLICATIONINFO RMATIONUS EPA Record Keeping IS REQUIRED FOR THE applications OF THIS PRODUCT. The applicator must keep the following records for a period of two years Records must be generated as soon as practical but no later than 14 days after Application Refer to appropriate state labeling for additional recordkeeping requirements A separate Record must be kept for each Application and each location A blank Record Keeping form can be downloaded at: Application START: Application END: Time: Air Temperature ( F): Wind Speed (at boom height): Wind Direction (direction from which wind is blowing).

3 Approved Dicamba Rate Per Acre: Spray Volume Applied ( ): Tank-Mix Products* (brand names and EPA reg #s, if applicable): Spray System Equipment Cleanout (triple rinse): (notes) Application Timing (Check only one)Date Crop PlantedN/A Burndown N/A Pre-Plant N/A At Planting Pre-Emergence Postemergence *Label requires the applicator must check the list of tested products at no more than 7 days prior to applicationDuPont fexapan herbicide plus vaporgrip Technology is a restricted-use pesticide. DuPont fexapan herbicide plus vaporgrip Technology is not registered for sale or use in all states. Contact your DuPont retailer or representative for details and availability in your state.

4 IT IS A VIOLATION OF FEDERAL AND STATE LAW TO MAKE AN IN-CROP Application OF ANY DICAMBA HERBICIDE PRODUCT ON SOYBEANS WITH Roundup Ready 2 Xtend technology, OR ANY OTHER PESTICIDE Application , UNLESS THE PRODUCT LABELING SPECIFICALLY AUTHORIZES THE USE. Contact the EPA and your state pesticide regulatory agency with any questions about the approval status of dicamba herbicide products for in-crop use with soybeans with Roundup Ready 2 Xtend technology and follow all pesticide product labeling. Glyphosate herbicides will kill crops that are not tolerant to glyphosate. Dicamba will kill crops that are not tolerant to dicamba. Always read and follow all label directions and precautions for use when using any pesticide alone or in tank-mix combinations. Unless indicated, trademarks with , TM or SM are trademarks of DuPont or affiliates.

5 Xtend , XtendFlex , vaporgrip , Roundup Ready 2 Xtend (Monsanto). vaporgrip Technology is used under license from Monsanto Technology LLC. 2017 DuPont . P39600001 DAS (12/17) 010-95008 Additional Notes and Records.