Florida Department of Agriculture and Consumer Services
Program ID
Division of Agricultural Environmental Services
(FDACS USE)
REQUEST FOR GRANTING CONTINUING EDUCATION UNITS
Rule 5E-9.029, F.A.C.
ADAM H. PUTNAM
Pesticide Certification Section - Telephone: (850) 617-7870 FAX (850) 617-7895
COMMISSIONER
Form must be completely filled out and necessary documentation attached. Please see Terms for Approval and Address for
Submission on back of this form.
Provider:
Title of Program: _____________________________________________________________________________________________
Location: Building or Address:
City
State
County
Zip Code
Program Start Date _____/_____/_____to_____/_____/_____ (if applicable). Please list additional dates and locations (including
addresses) on separate sheet, if necessary.
Estimated number of attendees (# of attendance forms needed): _____________
Bureau of Compliance Monitoring (BCM)
Bureau of Compliance Monitoring (BCM)
Bureau of Entomology and Pest Control (BEPC)
#CEUs
#CEUs
#CEUs
#CEUs
#CEUs
#CEUs
Approved
Approved
Approved
Requested
Requested
Requested
487 General Standards/Core
Natural Areas Weed Mgmt
482 General Standards/Core
Private Applicator - Ag
Ornamental & Turf
Limited Urban Fertilizer
Aerial Application
Raw Ag Commodity Fumigation
Limited Wildlife Trapper
Ag Animal
Regulatory Inspection & Sampling
Limited Landscape Maintenance
Ag Row Crop
Regulatory Pest Control
Limited Lawn & Ornamental
Ag Tree Crop
Right-of-Way
Limited Structural
Antifouling Paint
Seed Treatment
Commercial Lawn & Ornamental
Aquatic Weed Control
Sewer Root Control
Commercial General Household Pest
Chlorine Gas Infusion
Soil & Greenhouse Fumigation
Commercial Termite
Demo & Research
Wood Treatment
Commercial Structural Fumigation
Forestry
Public Health
TOTAL CEU HOURS AWARDED FOR PROGRAM:
Provider Name
Affiliation
Mailing Address
Phone Number of Contact Person
City
State
Zip Code
Signature of Provider
Date
Email Address:
FDACS -13326 Rev. 10/13
Page 1 of 2
Florida Department of Agriculture and Consumer Services
Program ID
Division of Agricultural Environmental Services
(FDACS USE)
REQUEST FOR GRANTING CONTINUING EDUCATION UNITS
Rule 5E-9.029, F.A.C.
ADAM H. PUTNAM
Pesticide Certification Section - Telephone: (850) 617-7870 FAX (850) 617-7895
COMMISSIONER
Form must be completely filled out and necessary documentation attached. Please see Terms for Approval and Address for
Submission on back of this form.
Provider:
Title of Program: _____________________________________________________________________________________________
Location: Building or Address:
City
State
County
Zip Code
Program Start Date _____/_____/_____to_____/_____/_____ (if applicable). Please list additional dates and locations (including
addresses) on separate sheet, if necessary.
Estimated number of attendees (# of attendance forms needed): _____________
Bureau of Compliance Monitoring (BCM)
Bureau of Compliance Monitoring (BCM)
Bureau of Entomology and Pest Control (BEPC)
#CEUs
#CEUs
#CEUs
#CEUs
#CEUs
#CEUs
Approved
Approved
Approved
Requested
Requested
Requested
487 General Standards/Core
Natural Areas Weed Mgmt
482 General Standards/Core
Private Applicator - Ag
Ornamental & Turf
Limited Urban Fertilizer
Aerial Application
Raw Ag Commodity Fumigation
Limited Wildlife Trapper
Ag Animal
Regulatory Inspection & Sampling
Limited Landscape Maintenance
Ag Row Crop
Regulatory Pest Control
Limited Lawn & Ornamental
Ag Tree Crop
Right-of-Way
Limited Structural
Antifouling Paint
Seed Treatment
Commercial Lawn & Ornamental
Aquatic Weed Control
Sewer Root Control
Commercial General Household Pest
Chlorine Gas Infusion
Soil & Greenhouse Fumigation
Commercial Termite
Demo & Research
Wood Treatment
Commercial Structural Fumigation
Forestry
Public Health
TOTAL CEU HOURS AWARDED FOR PROGRAM:
Provider Name
Affiliation
Mailing Address
Phone Number of Contact Person
City
State
Zip Code
Signature of Provider
Date
Email Address:
FDACS -13326 Rev. 10/13
Page 1 of 2
TERMS FOR APPROVAL
In making this request, the organization listed on the front agrees to comply with the following criteria:
1.
The subject matter to be presented for CEU credit must relate directly to the certification standards.
2.
The trainers or presenters must possess the expertise required to impart the specified information to the
attendees.
3.
The Record of Attendance (DACS-13325) must show the name, address, applicator license number, date,
and sign-in and sign-out times for each attendee desiring CEU credit. All information on the record must be
legible.
4.
The attendee (applicator) will receive the original copy of the Record of Attendance form following the
program attended. It is the responsibility of the applicator to keep these records of CEUs earned. The
Provider may also keep a copy of the form for future reference. Record of Attendance forms will not be
forwarded to FDACS by the Provider. The education provider must enter licensed attendees into the CEU
Database within two weeks after completion of the class.
5.
For each session for which approval is requested, the provider will specify the duration (time) and request
the number of CEUs to be allowed. This is normally 1 CEU for each 50 minutes of instruction time, or 0.5
CEU for each 50 minutes of demonstration time (for Bureau of Compliance Monitoring only), for applicable
sections of the program.
6.
The provider must submit each of the following for verification of program content, applicability, and
assignment of CEU credits:
Program agenda including a list of the contact hours of instruction time
Brief description of the specific program contents as noted on the agenda
Documentation that attests the expertise of each trainer or presenter (brief resume)
7.
Forms and information should be submitted at least 3 weeks before the program. All programs must
be approved before the presentation in order to receive CEU credits.
8.
Authorized Department agents may attend any approved CEU session unannounced and without
paying any associated registration fee. If these agents desire to earn CEU credits while monitoring
approved training programs, they must follow the same protocol as other attendees for registering and
paying fees, if applicable.
For assistance, please call the Pesticide Certification Section at (850) 617-7870.
ADDRESS FOR SUBMISSION:
Send this form with appropriate documentation (#6 above) to:
Pesticide Certification Section
3125 Conner Blvd. Bldg. 8
Tallahassee, FL 32399-1650
Fax (850) 617-7895
FDACS -13326 Rev. 10/13
Page 2 of 2