Delaware Department of Agriculture
Pesticide Compliance
2320 S. DuPont Hwy., Dover, DE 19901
Tel. (302) 698-4571
Fax (302) 697-4483
(800) 282-8685 – DE Only
TERMINATION OF REGISTERED EMPLOYEE AND/OR CERTIFIED APPLICATOR
Business Name and Address:
Name
Business License Number
Street
City
State
Zip
Telephone Number
Date of
Check if I.D. Card
Employee Name
Social Security No.
Certification No.
Termination
Returned
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Name of Authorized Individual:
Print Name
Signature
Date
Document No. 65-01-06/02/08/02
Delaware Department of Agriculture
Pesticide Compliance
2320 S. DuPont Hwy., Dover, DE 19901
Tel. (302) 698-4571
Fax (302) 697-4483
(800) 282-8685 – DE Only
TERMINATION OF REGISTERED EMPLOYEE AND/OR CERTIFIED APPLICATOR
Business Name and Address:
Name
Business License Number
Street
City
State
Zip
Telephone Number
Date of
Check if I.D. Card
Employee Name
Social Security No.
Certification No.
Termination
Returned
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Name of Authorized Individual:
Print Name
Signature
Date
Document No. 65-01-06/02/08/02
