"Application for a Pesticide Business License" - Delaware

Application for a Pesticide Business License is a legal document that was released by the Delaware Department of Agriculture - a government authority operating within Delaware.

Form Details:

  • Released on August 1, 2001;
  • The latest edition currently provided by the Delaware Department of Agriculture;
  • Ready to use and print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Delaware Department of Agriculture.

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Download "Application for a Pesticide Business License" - Delaware

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For Departmental Use Only
Business License# __________
Certified App.# _____________
State of Delaware
Delaware Department of Agriculture
Ins. Expiration _____________
Pesticide Compliance
Service Employee(s) Yes No
2320 S. DuPont Hwy., Dover, DE 19901
Category(ies) ______________
(302) 698-4571
Fax (302) 697-4483
Approval __________________
Delaware Only (800) 282-8685
APPLICATION FOR A PESTICIDE BUSINESS LICENSE
I,
in accordance with the provision of Sections 1206 through 1223
(Name)
inclusive, State of Delaware Code, Title 3, Part II, Chapter 12, hereby apply for a license to operate a
a pesticide application business in the name of:
* Firm Name
Address (principal place of business)
City
State
Zip Code
Telephone Number
1.
(a)
If a partnership or association, the name and address of each partner or association officer:
(1.)
(2.)
(b)
If a corporation, please complete the following:
(1.)
Date Incorporated
(2.)
State Incorporated
(3.)
Address of principal office
(4.)
Name and address of resident agent
2.
Address of branch office(s) in Delaware (or that operate in Delaware)
Address
City
State
Zip Code
Address
City
State
Zip Code
Address
City
State
Zip Code
* If an assumed name and not incorporated, enclose a notarized “Doing Business As” certificate.
Application for Pesticide Business License
Page 1 of 4
Document No. 65-01-06/01/08/01
For Departmental Use Only
Business License# __________
Certified App.# _____________
State of Delaware
Delaware Department of Agriculture
Ins. Expiration _____________
Pesticide Compliance
Service Employee(s) Yes No
2320 S. DuPont Hwy., Dover, DE 19901
Category(ies) ______________
(302) 698-4571
Fax (302) 697-4483
Approval __________________
Delaware Only (800) 282-8685
APPLICATION FOR A PESTICIDE BUSINESS LICENSE
I,
in accordance with the provision of Sections 1206 through 1223
(Name)
inclusive, State of Delaware Code, Title 3, Part II, Chapter 12, hereby apply for a license to operate a
a pesticide application business in the name of:
* Firm Name
Address (principal place of business)
City
State
Zip Code
Telephone Number
1.
(a)
If a partnership or association, the name and address of each partner or association officer:
(1.)
(2.)
(b)
If a corporation, please complete the following:
(1.)
Date Incorporated
(2.)
State Incorporated
(3.)
Address of principal office
(4.)
Name and address of resident agent
2.
Address of branch office(s) in Delaware (or that operate in Delaware)
Address
City
State
Zip Code
Address
City
State
Zip Code
Address
City
State
Zip Code
* If an assumed name and not incorporated, enclose a notarized “Doing Business As” certificate.
Application for Pesticide Business License
Page 1 of 4
Document No. 65-01-06/01/08/01
3.
This business applies for a license to perform Pest Control in the following categories*
* Categories defined by section 7 of the Rules and Regulations pursuant to Delaware Pesticide Law.
Name of Certified Person In Each Category
Category
(Attach sheet if necessary)
Agricultural Plant (1A)
Agricultural Animal (1B)
Fumigation of Soil and Ag. Products (1C)
Forest (02)
Ornamental and Turf (03)
Seed Treatment (04)
Aquatic (5A)
Anti-Fouling Paint (5B)
Mosquito (5C)
Right-of-Way (06)
General Pest Control (7A)
Wood Destroying Pest Control (7B)
Fumigation Pest Control (7C)
Wood Preservatives (7D)
Institutional & Maintenance Pest Ctrl. (7E)
Cooling Tower Pest Control (7F)
Miscellaneous (7G)
Public Health (08)
Regulatory (09)
Demonstration and Research (10)
4.
At least one of the certified applicators must have a minimum of two years practical
experience under the supervision of a certified applicator. This experience shall have been
acquired during the previous three-year period, and shall be related to the license
classification at issue. This requirement applies to aerial applicators and the structural pest
control industry (categories 7A, 7B and 7C) only. Please provide proof of two years
practical experience if application is for these categories of pest control.
5.
Principal areas of state serviced:
6.
Amount of insurance carried **
**Certificate of Insurance with expiration date and policy number must be enclosed with the application.
Minimum amount of coverage is $300,000 for Bodily Injury or Death and $100,000 for Property Damage.
Liability:
Bodily Injury or Death Each Occurrence
Property Damage
Application for Pesticide Business License
Page 2 of 4
Document No. 65-01-06/01/08/01
7.
Have you ever had a civil judgment entered against you arising out of the application of
pesticides?
YES
NO
If yes, give particulars on a separate sheet.
8.
Have you ever been arrested, convicted or fined in connection with your use of pesticides?
YES
NO
If yes, give particulars on a separate sheet.
9.
List the names of all service personnel employed by your company that are certified in
Delaware. In order to list new employees, they must first watch the Service Employee DVD
sold by the Delaware Department of Ag for $20.00. Call 302-698-4575.
(1.)
Last Name
First Name
Middle
Address
City
State
Zip Code
Date of Birth
Social Security Number
Primary Duty
Signature of Employee
(2.)
Last Name
First Name
Middle
Address
City
State
Zip Code
Date of Birth
Social Security Number
Primary Duty
Signature of Employee
(3.)
Last Name
First Name
Middle
Address
City
State
Zip Code
Date of Birth
Social Security Number
Primary Duty
Signature of Employee
10.
Non-resident pesticide applicator only:
I (we) hereby appoint
Address
City
State
Zip Code
As process agent to accept service of notice or process arising in any court from any action,
criminal or civil, resulting from my (our) operations in the State of Delaware.
(You may
designate the Secretary of State, State of Delaware, as your agent pursuant to 3 DEL C., Section 1213. You must
request approval from the Secretary of State for such designation.)
11.
Please enclose check or money order for $50.00 to Delaware Department of
Agriculture or complete credit card information section on page 4, for payment of annual
license fee (January 1 through December 31). As an option, you may purchase a biennial
license (2 years) for $100.00.
Application for Pesticide Business License
Page 3 of 4
Document No. 65-01-06/01/08/01
12.
This is to certify that the foregoing is true and accurate to the best of my knowledge and
belief and I (we) will comply with the provisions of Title 3, Part II, Chapter 12, Sections
1206 and 1224, Annotated Code of Delaware, Pesticide Law, Revised July 29, 1999.
I further agree that I will permit any authorized agent of the Delaware Department of
Agriculture to have access during all operating hours and business hours to any equipment
used in or intended for use in pesticide operations, or to any premise from which I or my
firm operates and to have access to books and records of pesticide applications for the
purpose of investigation and administration of the provisions of law relating to the use of
pesticides.
Dated this
day of
, 20
.
Notary Seal
Signature of Applicant
Title
Signature (Notary)
Date
CHECK/MONEY ORDER
NEW!!!
CREDIT CARD (Please check one or two years)
$50 for one year license
$50 for one year license
Visa
MasterCard
Discover
Billing Name:
Make Check or Money Order
Credit Card Billing
Address:
Payable to:
City/State/Zip:
*
Credit Card Number:
CVC #
Delaware Department of
/
Expiration Date:
Agriculture
Month
Year
Authorization:
*This number can found on the back of your card. It is a 3 or 4 digit #.
Application for Pesticide Business License
Page 4 of 4
Document No. 65-01-06/01/08/01
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