Consent form

CONSENT FORM

I, , give the University of Connecticut and their

authorized agent(s) permission, with reasonable notice, to enter upon property

located at , , Connecticut for the

(street address) (town)

purpose of conducting a research study of and introducing beneficial insects for

biological control of purple loosestrife, Lythrum salicaria.

The research study and beneficial insect introductions will begin during the 201_ calendar year.

We request that you sign below and return a copy to Donna Ellis, University of Connecticut,
Department of Plant Science and Landscape Architecture, 1390 Storrs Road, Unit 4163, Storrs,
Connecticut 06269-4163.
Email address donna.ellis@uconn.edu Telephone (860) 486-6448 FAX (860) 486-0534

Dated at , Connecticut this day of , 201_.

(town)

____________________________ ______________________________