Form FDACS-13610 "Limited Certification for Government Pesticide Applicators or Private Applicators" - Florida

Form FDACS-13610 or the "Limited Certification For Government Pesticide Applicators Or Private Applicators" is a form issued by the Florida Department of Agriculture and Consumer Services.

Download a PDF version of the Form FDACS-13610 down below or find it on the Florida Department of Agriculture and Consumer Services Forms website.

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Download Form FDACS-13610 "Limited Certification for Government Pesticide Applicators or Private Applicators" - Florida

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Florida Department of Agriculture and Consumer Services
Remit Fee Online at:
Division of Agricultural Environmental Services
www.FreshFromFlorida.com
- or -
Check or Money Order Payable to
LIMITED CERTIFICATION FOR GOVERNMENT
FDACS:
PESTICIDE APPLICATORS OR PRIVATE APPLICATORS
FDACS
Revenue Processing Section
ADAM H. PUTNAM
P.O. Box 6710
Rule 5E-14.117, F.A.C.
COMMISSIONER
Tallahassee, FL 32314-671
Telephone: (850) 617-7997
REMIT SEPARATE CHECKS FOR EACH APPLICATION
IMPORTANT - DIRECTIONS:
(1)
Applicant must be 18 years of age or older to apply.
DO NOT SEND CASH.
(2)
Enclose a check or money order payable to FDACS in the amount of $150.00.
PLEASE REMIT SEPARATE CHECKS FOR EACH APPLICATION.
I hereby make application for Limited Certification in the categories checked.
– 001367
STRUCTURAL PEST CONTROL
$
150.00
– 001366
LAWN AND ORNAMENTAL PEST CONTROL
$
150.00
TOTAL FEES ENCLOSED
$
All questions MUST be answered. PLEASE PRINT.
1.
Name of Applicant
(Last)
(First)
(Middle)
Mailing Address
(Street or Post Office Box)
(City)
(County)
(State)
(Zip Code)
Telephone Number (
)
Email Address
(Area Code)
FL Driver’s License Number (or State ID)
2.
Name of Employer
(if applicable)
Street Address
(Street)
(City)
(County)
(State)
(Zip Code)
Employer Phone No. (
)
(Area Code)
3.
Have you previously been examined and failed in the category(s) now applied for?
YES
NO
If yes, give month and year FIRST examined in category:
Structural
Lawn and Ornamental ___________________________________
(Month)
(Year)
(Month)
(Year)
Date of Birth:
(Month)
(Day)
(Year)
Org. Code: 42 13 08 02 060
EO B7
_________________________________________
Object Code: 001367
$ 150.00
(Applicant’s Signature)
001366
$ 150.00
County to be examined in
FDACS-13610 Rev. 10/15
Florida Department of Agriculture and Consumer Services
Remit Fee Online at:
Division of Agricultural Environmental Services
www.FreshFromFlorida.com
- or -
Check or Money Order Payable to
LIMITED CERTIFICATION FOR GOVERNMENT
FDACS:
PESTICIDE APPLICATORS OR PRIVATE APPLICATORS
FDACS
Revenue Processing Section
ADAM H. PUTNAM
P.O. Box 6710
Rule 5E-14.117, F.A.C.
COMMISSIONER
Tallahassee, FL 32314-671
Telephone: (850) 617-7997
REMIT SEPARATE CHECKS FOR EACH APPLICATION
IMPORTANT - DIRECTIONS:
(1)
Applicant must be 18 years of age or older to apply.
DO NOT SEND CASH.
(2)
Enclose a check or money order payable to FDACS in the amount of $150.00.
PLEASE REMIT SEPARATE CHECKS FOR EACH APPLICATION.
I hereby make application for Limited Certification in the categories checked.
– 001367
STRUCTURAL PEST CONTROL
$
150.00
– 001366
LAWN AND ORNAMENTAL PEST CONTROL
$
150.00
TOTAL FEES ENCLOSED
$
All questions MUST be answered. PLEASE PRINT.
1.
Name of Applicant
(Last)
(First)
(Middle)
Mailing Address
(Street or Post Office Box)
(City)
(County)
(State)
(Zip Code)
Telephone Number (
)
Email Address
(Area Code)
FL Driver’s License Number (or State ID)
2.
Name of Employer
(if applicable)
Street Address
(Street)
(City)
(County)
(State)
(Zip Code)
Employer Phone No. (
)
(Area Code)
3.
Have you previously been examined and failed in the category(s) now applied for?
YES
NO
If yes, give month and year FIRST examined in category:
Structural
Lawn and Ornamental ___________________________________
(Month)
(Year)
(Month)
(Year)
Date of Birth:
(Month)
(Day)
(Year)
Org. Code: 42 13 08 02 060
EO B7
_________________________________________
Object Code: 001367
$ 150.00
(Applicant’s Signature)
001366
$ 150.00
County to be examined in
FDACS-13610 Rev. 10/15
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