Form FDACS-13315 "Notification of Examination Results" - Florida

What Is Form FDACS-13315?

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

Form Details:

  • Released on October 1, 2013;
  • The latest edition provided by the Florida Department of Agriculture and Consumer Services;
  • 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 FDACS-13315 by clicking the link below or browse more documents and templates provided by the Florida Department of Agriculture and Consumer Services.

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Download Form FDACS-13315 "Notification of Examination Results" - Florida

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Department of Agriculture and Consumer Services
Florida
Submit to:
Division of Agricultural Environmental Services
Pesticide Certification Section
3125 Conner Blvd., Bldg. 8
Tallahassee, FL 32399-1650
NOTIFICATION OF EXAMINATION RESULTS
Rule 5E-9.026, F.A.C.
ADAM H. PUTNAM
Telephone: (850) 617-7870; FAX (850) 617-7895
COMMISSIONER
Please Print
Exam Site:
Exam Administrator:
Exam Date
All questions must be answered. Use “None” or “N/A” (not applicable) if appropriate.
1. Legal Name:
(
)
Last
First
Middle
Suffix (Jr., Sr., etc.)
Nickname (optional)
2.
Date of Birth (month, day, year)
3.
4.
Home Address (physical address)
Mailing Address (If different from home)
City
State
Zip Code
City
State
Zip Code
County
County
5.
6.
Home Phone
E-mail Address
This request is for:
New license
Additional category
License renewal
8. License #:
Exp. Date:
7.
9.
License type requested:
Private RUP
Public RUP
Commercial RUP
Public Health
No license requested/adding a category
10.
Application sites (crops, right-of-ways, golf course, etc.):
Please Note: If applying for a public license, proof of
11.
Will this license be used in conjunction with your employment?
Yes
No
.
employment by a government entity may be required
12.
Is your employer a government entity? (examples: DOT, county parks and recreation, etc.)
Yes
No
13.
Name of Employer or Business
14.
Business Address
City
County
Zip Code
15.
16.
Business Phone No. (with area code)
Cell Phone No. (with area code)
17. I understand that passing the certification exams does not authorize me to purchase or apply restricted use pesticides (RUPs). A license must be issued to authorize RUP
purchase and application.
Signature
Date
NOTE: EXAM RESULTS ARE VALID FOR ONE YEAR FROM THE DATE OF EXAM.
IF LICENSE HAS NOT BEEN ISSUED WITHIIN ONE YEAR FROM EXAM DATE, EXAM(S) MUST BE RETAKEN.
DO NOT WRITE IN THIS BLOCK - OFFICIAL USE ONLY
Aerial
Demo/Research
Public Health
Sewer Root Control
Ag Animal
Forestry
Raw Ag Comm Fum
Soil/Greenhouse Fum
Ag Row Crop
Natural Areas
Regulatory
Wood Treatment
Ag Tree Crop
Organotin Paint
Reg Insp/Samp
WPS Crop Advisor Exemption
Aquatic
Ornamental/Turf
Right-of-Way
General Standards *(Core)
Chlorine Gas
Private Appl Ag
Seed Treatment
P=Pass F=Fail
Signature of FDACS Official Grading Exams
Date
Original: Pesticide Certification Section
Copies: Exam Administrator and Examinee
FDACS-13315 Rev. 10/13
Page 1 of 2
Department of Agriculture and Consumer Services
Florida
Submit to:
Division of Agricultural Environmental Services
Pesticide Certification Section
3125 Conner Blvd., Bldg. 8
Tallahassee, FL 32399-1650
NOTIFICATION OF EXAMINATION RESULTS
Rule 5E-9.026, F.A.C.
ADAM H. PUTNAM
Telephone: (850) 617-7870; FAX (850) 617-7895
COMMISSIONER
Please Print
Exam Site:
Exam Administrator:
Exam Date
All questions must be answered. Use “None” or “N/A” (not applicable) if appropriate.
1. Legal Name:
(
)
Last
First
Middle
Suffix (Jr., Sr., etc.)
Nickname (optional)
2.
Date of Birth (month, day, year)
3.
4.
Home Address (physical address)
Mailing Address (If different from home)
City
State
Zip Code
City
State
Zip Code
County
County
5.
6.
Home Phone
E-mail Address
This request is for:
New license
Additional category
License renewal
8. License #:
Exp. Date:
7.
9.
License type requested:
Private RUP
Public RUP
Commercial RUP
Public Health
No license requested/adding a category
10.
Application sites (crops, right-of-ways, golf course, etc.):
Please Note: If applying for a public license, proof of
11.
Will this license be used in conjunction with your employment?
Yes
No
.
employment by a government entity may be required
12.
Is your employer a government entity? (examples: DOT, county parks and recreation, etc.)
Yes
No
13.
Name of Employer or Business
14.
Business Address
City
County
Zip Code
15.
16.
Business Phone No. (with area code)
Cell Phone No. (with area code)
17. I understand that passing the certification exams does not authorize me to purchase or apply restricted use pesticides (RUPs). A license must be issued to authorize RUP
purchase and application.
Signature
Date
NOTE: EXAM RESULTS ARE VALID FOR ONE YEAR FROM THE DATE OF EXAM.
IF LICENSE HAS NOT BEEN ISSUED WITHIIN ONE YEAR FROM EXAM DATE, EXAM(S) MUST BE RETAKEN.
DO NOT WRITE IN THIS BLOCK - OFFICIAL USE ONLY
Aerial
Demo/Research
Public Health
Sewer Root Control
Ag Animal
Forestry
Raw Ag Comm Fum
Soil/Greenhouse Fum
Ag Row Crop
Natural Areas
Regulatory
Wood Treatment
Ag Tree Crop
Organotin Paint
Reg Insp/Samp
WPS Crop Advisor Exemption
Aquatic
Ornamental/Turf
Right-of-Way
General Standards *(Core)
Chlorine Gas
Private Appl Ag
Seed Treatment
P=Pass F=Fail
Signature of FDACS Official Grading Exams
Date
Original: Pesticide Certification Section
Copies: Exam Administrator and Examinee
FDACS-13315 Rev. 10/13
Page 1 of 2
Instructions for Completing Form
Clearly print all the information for each item except your signature. Sign in the signature block (#17). Be sure to complete every
item. Use “None” or “N/A” (not applicable) if appropriate. Signature is required for exam scores to be valid.
1.
Your complete legal name (required) and nickname (optional).
2.
Your birth date (required to verify age qualification for license).
3.
Your complete home address, including your county of residence. Please do not give a P.O. Box as your home address.
4.
Your complete mailing address, including county.
5.
Your home telephone number.
6.
Your e-mail address.
7.
Please indicate if you are testing to obtain a new license, add a category to an existing license, or renew an existing license.
8.
If you have a pesticide applicator license (current or expired), indicate the license number. If none, write “None.”
9.
Check the license type you are requesting. If adding a category, check “Not Applicable.” RUP=Restricted Use Pesticide.
Items 10, 11, 12 and 13 will be used to help determine the license type you need.
10. Give a brief description of where you will be applying restricted use pesticides. Examples: citrus application--my own groves;
citrus application--groves I care take for others; golf course; plant nursery--at place of employment; roadsides/rights-of-way--
contract to DOT; roadsides--for employer (DOT); wetland areas--for work at state park, etc.
11. If this license will be used to make or supervise restricted use pesticide applications as part of your employment, check “YES”.
If your license will be used for a purpose other than for your work, check “NO”.
12. If your employer is a government entity, check “YES”. If your employer is not a government entity, check “NO”.
13. The name of your employer or your own business (if self employed).
14. Your complete business address, including county (at place of employment).
15. Your business telephone number (at place of employment).
16. Your cell phone number.
17. Your signature and the date (required).
Definitions
Private Applicator - This is someone aged 18 or older who uses or supervises the use of restricted use pesticides to grow some type
of agricultural product, such as field crops, vegetables, citrus, tree fruits or nuts, nursery plants, sod, timber, livestock, catfish, etc. in
their own business or for their employer. The restricted use pesticide applications must be made to property owned or leased by the
private applicator or his/her employer. No contract applications may be made with this license. However, applications may be made to
the property of another agricultural producer if the pesticide is applied without compensation other than the trading of personal services
between producers of agricultural commodities. This license is not valid for making applications to maintain lawns or landscape
ornamental plants, including those at the private applicator’s residence.
Public Applicator - This is someone aged 18 or older who uses restricted use pesticide as part of his/her job while employed by a
government agency or entity. The employer may be a federal agency, state agency or institution, county government, municipal
corporation, city government, or any other government entity. The type of work may involve any agricultural or other outdoor pesticide
application. Exceptions: this license type does not cover public health pest control (mosquitoes, biting flies, etc.) or pest control on
lawns and ornamentals associated with buildings. Examples of application sites covered by this license: all of the agricultural areas
mentioned above for private applicators; lakes and other aquatic sites; right-of-way areas; sewer lines for root control; ornamentals and
turf not associated with buildings; seed treatment; wood treatment; boat bottoms (antifouling paint); etc. This license is not valid for
application to buildings for structural pest control or for control of pests on lawns and ornamentals immediately surrounding (within 10
feet of) any building.
Commercial Applicator - This is someone aged 18 or older who makes contract applications of restricted use pesticides on
agricultural sites (see list above under private applicator) or contract or employment-related applications to non-agricultural outdoor sites
such as golf courses, parks, and cemeteries; ornamentals and turf not immediately associated with buildings; recreational lakes and
other aquatic sites; right-of-way areas; sewer lines for root control; seed treatment; wood treatment; boat bottoms (antifouling paint);
etc. This license is not valid for application to buildings for structural pest control or for control of pests on lawns and ornamentals
immediately surrounding (within 10 feet of) any building. A commercial applicator license may substitute for a private or public
applicator license if desired, but liability issues should be taken into consideration.
FDACS-13315 Rev. 10/13
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