1
2Form DP-28 (Rev. 4/18)
APPLICATION FOR A COMMERCIAL
APPLICATOR TECHNICIAN LICENSE
For the Year Ending December 31, 20___
Instructions: Complete and submit with appropriate fees to the Arkansas State Plant Board, P.O. Box 1069, Little Rock,
Arkansas 72203.
PRINT OR TYPE ONLY. Upon approval, your license will be issued for the year indicated.
Incomplete application will delay processing.
Note: To qualify for this license an individual must have been trained within four months of submitting this application.
PERSON APPLYING
Name: Last
First
Middle __________________
Date of Birth _________________________________
Mailing Address
City _________________________________
State
Zip Code
County ________________________________________
Home Phone # (
)
- _______________
Work Phone # (
)
- _______________
Fax #
(
)
- _______________
E-mail address __________________________________
Cell Phone #
(
)
- _______________ (Opt)
List the licensed firm(s) that you plan on working for during the year ending December 31, 20___
________________________________________________
________________________________________________
I do hereby attest that I have read and am familiar with the Pesticide Use and Application Act and the Regulations adopted
thereunder.
Applicant’s
Signature:
Date: ____________________
□
APPLICATION FEE ENCLOSED:
$25
This application is considered incomplete unless the second page (Required Confidential Information
Form) is completed.
******************************************************************************************
DO NOT WRITE IN THIS SPACE
__
________
License Number
Date of Issuance
Form DP-28 (Rev. 4/18)
APPLICATION FOR A COMMERCIAL
APPLICATOR TECHNICIAN LICENSE
For the Year Ending December 31, 20___
Instructions: Complete and submit with appropriate fees to the Arkansas State Plant Board, P.O. Box 1069, Little Rock,
Arkansas 72203.
PRINT OR TYPE ONLY. Upon approval, your license will be issued for the year indicated.
Incomplete application will delay processing.
Note: To qualify for this license an individual must have been trained within four months of submitting this application.
PERSON APPLYING
Name: Last
First
Middle __________________
Date of Birth _________________________________
Mailing Address
City _________________________________
State
Zip Code
County ________________________________________
Home Phone # (
)
- _______________
Work Phone # (
)
- _______________
Fax #
(
)
- _______________
E-mail address __________________________________
Cell Phone #
(
)
- _______________ (Opt)
List the licensed firm(s) that you plan on working for during the year ending December 31, 20___
________________________________________________
________________________________________________
I do hereby attest that I have read and am familiar with the Pesticide Use and Application Act and the Regulations adopted
thereunder.
Applicant’s
Signature:
Date: ____________________
□
APPLICATION FEE ENCLOSED:
$25
This application is considered incomplete unless the second page (Required Confidential Information
Form) is completed.
******************************************************************************************
DO NOT WRITE IN THIS SPACE
__
________
License Number
Date of Issuance
