Form FDACS-13359 Request for Change of Information for Pesticide Applicator License - Florida

Form FDACS-13359 is a Florida Department of Agriculture and Consumer Services form also known as the "Request For Change Of Information For Pesticide Applicator License". The latest edition of the form was released in September 1, 2011 and is available for digital filing.

Download an up-to-date Form FDACS-13359 in PDF-format down below or look it up on the Florida Department of Agriculture and Consumer Services Forms website.

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Florida Department of Agriculture and Consumer Services
Division of Agricultural Environmental Services
Please fax or mail to:
REQUEST FOR CHANGE OF INFORMATION
Pesticide Certification Section
3125 Conner Blvd., Bldg. 8
FOR PESTICIDE APPLICATOR LICENSE
Tallahassee, FL 32399-1650
ADAM H. PUTNAM
Section 487.046, F.S. and Rule 5E-9.026, F.A.C.
COMMISSIONER
Telephone: (850) 617-7870; FAX (850) 617-7895
Complete your name and license information plus other sections as needed to update your license file.
Legal Name:
Last
First
Middle
Suffix
License Type:
PUB License No:
PVT
COMM
Date of Birth:
Home E-Mail Address:
Business E-Mail Address:
Home Address:
Home Phone:
Home Phone 2:
Home Fax:
Mailing Address:
Cell Phone:
Pager/Beeper:
Business Phone:
Business Headquarters Phone:
Business Address:
Business Fax:
Other Phone/Fax:
Description:
(Include area code with all phone numbers)
I AM REQUESTING AN IMMEDIATE CHANGE TO THE INFORMATION LISTED ABOVE FOR MY
RESTRICTED USE PESTICIDE APPLICATOR LICENSE FILE.
Signature:
Date:
***** MUST BE SIGNED AND DATED *****
FDACS-13359 Rev. 09/11
Florida Department of Agriculture and Consumer Services
Division of Agricultural Environmental Services
Please fax or mail to:
REQUEST FOR CHANGE OF INFORMATION
Pesticide Certification Section
3125 Conner Blvd., Bldg. 8
FOR PESTICIDE APPLICATOR LICENSE
Tallahassee, FL 32399-1650
ADAM H. PUTNAM
Section 487.046, F.S. and Rule 5E-9.026, F.A.C.
COMMISSIONER
Telephone: (850) 617-7870; FAX (850) 617-7895
Complete your name and license information plus other sections as needed to update your license file.
Legal Name:
Last
First
Middle
Suffix
License Type:
PUB License No:
PVT
COMM
Date of Birth:
Home E-Mail Address:
Business E-Mail Address:
Home Address:
Home Phone:
Home Phone 2:
Home Fax:
Mailing Address:
Cell Phone:
Pager/Beeper:
Business Phone:
Business Headquarters Phone:
Business Address:
Business Fax:
Other Phone/Fax:
Description:
(Include area code with all phone numbers)
I AM REQUESTING AN IMMEDIATE CHANGE TO THE INFORMATION LISTED ABOVE FOR MY
RESTRICTED USE PESTICIDE APPLICATOR LICENSE FILE.
Signature:
Date:
***** MUST BE SIGNED AND DATED *****
FDACS-13359 Rev. 09/11

Download Form FDACS-13359 Request for Change of Information for Pesticide Applicator License - Florida

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