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 occur between May 1, 2009

and December 31, 2013.

We request that you sign below and return a copy to Donna Ellis,

University of Connecticut, Department of Plant Science, 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                     , 2009.

                          (town)

 
                                                                                 
Signature 
                                                

 ______________________________________                                                                                           

Witness