Form DPR-PML-002 "Address and/Or Name Change/Replacement Card Form for Individuals Only" - California

What Is Form DPR-PML-002?

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

Form Details:

  • Released on February 1, 2017;
  • The latest edition provided by the California Department of Pesticide Regulation;
  • 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 fillable version of Form DPR-PML-002 by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

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Download Form DPR-PML-002 "Address and/Or Name Change/Replacement Card Form for Individuals Only" - California

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DEPARTMENT OF PESTICIDE REGULATION
STATE OF CALIFORNIA
DPR-PML-002
PEST MANAGEMENT AND LICENSING BRANCH
(REV. 02/17)
LICENSING AND CERTIFICATION PROGRAM
P.O. Box 1379
SACRAMENTO, CALIFORNIA 95812
(916) 445-4038
E-Mail - licensemail@cdpr.ca.gov
Web site: http://www.cdpr.ca.gov
ADDRESS AND/OR NAME CHANGE/REPLACEMENT CARD FORM
For Individuals Only
Notify DPR of an address or name change immediately in accordance with Title 3, CCR Section 6508. DPR relies on its address
files for notifying licensees and certificate holders of upcoming license renewal and important communications. You can notify
DPR of any change by filling out this form, signing it, and sending it to us at: DPR Pest Management and Licensing Branch,
Licensing and Certification Program, P.O. Box 1379, Sacramento, CA 95812. Please check the appropriate request.
License or Certificate Type. Check one or more of the appropriate box(es).
Individual License or Certificate:
Qualified Applicator Certificate (QAC) #
Qualified Applicator License (QAL)
#
Agricultural Pest Control Adviser (PCA) #
Dealer Designated Agent (DDA)
#
#
Apprentice Pilot Certificate (APC)
#
Journeyman Pilot Certificate (JPC)
ADDRESS CHANGE:
A $20 fee is required when the license/certificate holder requests a new printed card to be issued with the address change.
Name:
(Name)
Previous Address:
(Number & Street or P.O. Box)
(City)
(State & Zip Code)
(County)
New Address:
(Number & Street or P.O. Box)
(City)
(State & Zip Code)
(County)
Phone Numbers:
(Work)
(Home/Cell)
(Fax)
(E-mail Address)
NAME CHANGE:
Name changes require a $20 fee and a copy of legal documentation such as marriage certificate or name change documents.
NOTE: DPR staff will contact you for additional information, if needed.
Previous Name:
New Name:
REPLACEMENT CARD ONLY:
A replacement license/certificate card requires a $20 fee.
Print Name:
Signature:
Date:
DEPARTMENT OF PESTICIDE REGULATION
STATE OF CALIFORNIA
DPR-PML-002
PEST MANAGEMENT AND LICENSING BRANCH
(REV. 02/17)
LICENSING AND CERTIFICATION PROGRAM
P.O. Box 1379
SACRAMENTO, CALIFORNIA 95812
(916) 445-4038
E-Mail - licensemail@cdpr.ca.gov
Web site: http://www.cdpr.ca.gov
ADDRESS AND/OR NAME CHANGE/REPLACEMENT CARD FORM
For Individuals Only
Notify DPR of an address or name change immediately in accordance with Title 3, CCR Section 6508. DPR relies on its address
files for notifying licensees and certificate holders of upcoming license renewal and important communications. You can notify
DPR of any change by filling out this form, signing it, and sending it to us at: DPR Pest Management and Licensing Branch,
Licensing and Certification Program, P.O. Box 1379, Sacramento, CA 95812. Please check the appropriate request.
License or Certificate Type. Check one or more of the appropriate box(es).
Individual License or Certificate:
Qualified Applicator Certificate (QAC) #
Qualified Applicator License (QAL)
#
Agricultural Pest Control Adviser (PCA) #
Dealer Designated Agent (DDA)
#
#
Apprentice Pilot Certificate (APC)
#
Journeyman Pilot Certificate (JPC)
ADDRESS CHANGE:
A $20 fee is required when the license/certificate holder requests a new printed card to be issued with the address change.
Name:
(Name)
Previous Address:
(Number & Street or P.O. Box)
(City)
(State & Zip Code)
(County)
New Address:
(Number & Street or P.O. Box)
(City)
(State & Zip Code)
(County)
Phone Numbers:
(Work)
(Home/Cell)
(Fax)
(E-mail Address)
NAME CHANGE:
Name changes require a $20 fee and a copy of legal documentation such as marriage certificate or name change documents.
NOTE: DPR staff will contact you for additional information, if needed.
Previous Name:
New Name:
REPLACEMENT CARD ONLY:
A replacement license/certificate card requires a $20 fee.
Print Name:
Signature:
Date: