Form DP-27 "Application for a Non-commercial Restricted Use Pesticide License" - Arkansas

What Is Form DP-27?

This is a legal form that was released by the Arkansas Agriculture Department - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Arkansas Agriculture Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DP-27 by clicking the link below or browse more documents and templates provided by the Arkansas Agriculture Department.

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Download Form DP-27 "Application for a Non-commercial Restricted Use Pesticide License" - Arkansas

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Form DP-27 (Rev. 4/18)
APPLICATION FOR A NON-COMMERCIAL
RESTRICTED USE PESTICIDE LICENSE
For the Year Ending December 31, 20_____
INSTRUCTIONS: Complete and submit with appropriate fees to the Arkansas State Plant Board, Pesticide Division, P.O. Box 1069,
Little Rock, Arkansas 72203. Upon approval, your license will be issued for the year indicated. Incomplete application will delay
processing. PRINT OR TYPE ONLY.
In accordance with Section 9 of the Pesticide Use and Application Act (copy available upon request), a non-commercial
license is requested by the following person or firm for the use, supervision and/or demonstration of the use of restricted
use pesticides (EPA restricted use pesticides and/or state restricted pesticides). Applicant verifies that he qualifies for the
non-commercial license as defined in Section 4(c)(4) of the above Act.
PERSON APPLYING
Name: Last
First
Middle ____________________
Name of Firm or Affiliate ___________________________________________________________________________________
Date of Birth _____________________
Mailing Address
City
State
Zip Code ____________
County
Home Phone # (
)
-
Work Phone # (
)
- ___________
Fax # (
)
-
E-mail address
Cell Phone # (
)
-
(Opt)
Indicate category(s) applied for (must be currently certified in each category indicated):
(1) Agricultural -Plants
(3) Aquatic
(1A) Agricultural - Animals
(4) Right- of Way
(2) Forest Pest Control
(5) Demonstration and Research
(2A) Wood Treatment
(6) Public Health
FEE: $35.00 per category
Amount $ _______________
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
Title
Date _____________
(PERSON APPLYING ONLY)
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-27 (Rev. 4/18)
APPLICATION FOR A NON-COMMERCIAL
RESTRICTED USE PESTICIDE LICENSE
For the Year Ending December 31, 20_____
INSTRUCTIONS: Complete and submit with appropriate fees to the Arkansas State Plant Board, Pesticide Division, P.O. Box 1069,
Little Rock, Arkansas 72203. Upon approval, your license will be issued for the year indicated. Incomplete application will delay
processing. PRINT OR TYPE ONLY.
In accordance with Section 9 of the Pesticide Use and Application Act (copy available upon request), a non-commercial
license is requested by the following person or firm for the use, supervision and/or demonstration of the use of restricted
use pesticides (EPA restricted use pesticides and/or state restricted pesticides). Applicant verifies that he qualifies for the
non-commercial license as defined in Section 4(c)(4) of the above Act.
PERSON APPLYING
Name: Last
First
Middle ____________________
Name of Firm or Affiliate ___________________________________________________________________________________
Date of Birth _____________________
Mailing Address
City
State
Zip Code ____________
County
Home Phone # (
)
-
Work Phone # (
)
- ___________
Fax # (
)
-
E-mail address
Cell Phone # (
)
-
(Opt)
Indicate category(s) applied for (must be currently certified in each category indicated):
(1) Agricultural -Plants
(3) Aquatic
(1A) Agricultural - Animals
(4) Right- of Way
(2) Forest Pest Control
(5) Demonstration and Research
(2A) Wood Treatment
(6) Public Health
FEE: $35.00 per category
Amount $ _______________
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
Title
Date _____________
(PERSON APPLYING ONLY)
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
Required Confidential Information Form
Pesticide Division
Instructions: Please print clearly. This information is confidential and required by Act 1163 of 1997.
The name below should appear the same as on the license application form.
Last Name
First Name
Middle Initial ________
Social Security Number
-
- __________
Do not write below this line
For Plant Board Use Only
Type of License(s) Issued
License Number
Private Applicator License ......................................
............................................. ________________
Commercial Individual License ..............................
............................................ ________________
Custom OIC Authorization Permit .........................
............................................. ________________
Custom Pilot’s Authorization Permit ......................
............................................ ________________
Non-Commercial License .......................................
............................................. ________________
Ginseng Dealer License ..........................................
............................................ ________________
Ginseng Man License..............................................
............................................ ________________
Landscape Contractors License ..............................
............................................. ________________
Pest Control License ...............................................
............................................ ________________
Ag Consultants License ..........................................
............................................ ________________
Seed Dealers License ..............................................
............................................ ________________
Seed Treaters License .............................................
............................................ ________________
Registered Seed Technologists License ..................
............................................ ________________
Other .....................................................................
............................................ ________________
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