Form FDACS-13002 "Special Training to Perform Fumigation Affidavit" - Florida

Form FDACS-13002 is a Florida Department of Agriculture and Consumer Services form also known as the "Special Training To Perform Fumigation Affidavit". The latest edition of the form was released in January 1, 2017 and is available for digital filing.

Download a fillable PDF version of the Form FDACS-13002 down below or find it on Florida Department of Agriculture and Consumer Services Forms website.

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Download Form FDACS-13002 "Special Training to Perform Fumigation Affidavit" - Florida

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Florida Department of Agriculture and Consumer Services
Respond to:
Division of Agricultural Environmental Services
Bureau of Licensing and
Enforcement
SPECIAL TRAINING TO PERFORM
3125 Conner Blvd, Bldg 8,
Tallahassee, FL 32399-1650
FUMIGATION AFFIDAVIT
ADAM H. PUTNAM
Rule 5E-14.1421, F.A.C.
COMMISSIONER
Telephone: (850) 617-7997
STATE OF FLORIDA,
COMPANY NAME
COUNTY OF
AND LICENSE NUMBER
ADDRESS
On this day personally appeared BEFORE ME, the undersigned authority, duly authorized to administer oaths and take acknowledgements,
(First Name)
(Middle Name)
(Last Name)
who resides at
(Street or rural address)
(City)
(State)
(Zip)
_________________________________________
__________________________________________________________
Date of Birth (mm/dd/yy)
Email Address
who being first duly sworn deposes and says as follows:
I hereby certify that I have received initial stewardship training associated with any or all residential fumigants used by the licensee and
adequate training under the supervision of a Certified Operator, certified in the category of pest control with respect to fumigation, in the proper
and safe handling and use of residential fumigants. I further certify that such training included the following:
(a) Initial Stewardship training as described in Chapter 5E-2.0312, Florida Administrative Code (F.A.C.);
(b) Proper Personal Protective Equipment, including Self Contained Breathing Apparatus as described in Chapter 5E-14.108, F.A.C.; and
(c) Applicable federal, state and local laws and ordinances.
I further certify that I will not perform a fumigation unless under the supervision of either a certified operator who is certified in the category of
fumigation; or a Special Identification Cardholder operating under authority of the certified operator in charge of the fumigation category.
I understand that an Identification Card issued and carrying with it authorization to perform fumigation shall be used in accordance with the provisions
of Sections 482.091, Florida Statutes.
Signature of prospective Identification Cardholder
Signature of Licensee or Certified Operator in Charge
Sworn to and Subscribed before me
Title or Position
this
day of
, A.D. 20
Personally Known:
Yes
No
SEAL
Produced ID: Type:
Notary Public
(This Affidavit is not required of Certified Operators certified in the category of fumigation).
FDACS-13002 01/17
Florida Department of Agriculture and Consumer Services
Respond to:
Division of Agricultural Environmental Services
Bureau of Licensing and
Enforcement
SPECIAL TRAINING TO PERFORM
3125 Conner Blvd, Bldg 8,
Tallahassee, FL 32399-1650
FUMIGATION AFFIDAVIT
ADAM H. PUTNAM
Rule 5E-14.1421, F.A.C.
COMMISSIONER
Telephone: (850) 617-7997
STATE OF FLORIDA,
COMPANY NAME
COUNTY OF
AND LICENSE NUMBER
ADDRESS
On this day personally appeared BEFORE ME, the undersigned authority, duly authorized to administer oaths and take acknowledgements,
(First Name)
(Middle Name)
(Last Name)
who resides at
(Street or rural address)
(City)
(State)
(Zip)
_________________________________________
__________________________________________________________
Date of Birth (mm/dd/yy)
Email Address
who being first duly sworn deposes and says as follows:
I hereby certify that I have received initial stewardship training associated with any or all residential fumigants used by the licensee and
adequate training under the supervision of a Certified Operator, certified in the category of pest control with respect to fumigation, in the proper
and safe handling and use of residential fumigants. I further certify that such training included the following:
(a) Initial Stewardship training as described in Chapter 5E-2.0312, Florida Administrative Code (F.A.C.);
(b) Proper Personal Protective Equipment, including Self Contained Breathing Apparatus as described in Chapter 5E-14.108, F.A.C.; and
(c) Applicable federal, state and local laws and ordinances.
I further certify that I will not perform a fumigation unless under the supervision of either a certified operator who is certified in the category of
fumigation; or a Special Identification Cardholder operating under authority of the certified operator in charge of the fumigation category.
I understand that an Identification Card issued and carrying with it authorization to perform fumigation shall be used in accordance with the provisions
of Sections 482.091, Florida Statutes.
Signature of prospective Identification Cardholder
Signature of Licensee or Certified Operator in Charge
Sworn to and Subscribed before me
Title or Position
this
day of
, A.D. 20
Personally Known:
Yes
No
SEAL
Produced ID: Type:
Notary Public
(This Affidavit is not required of Certified Operators certified in the category of fumigation).
FDACS-13002 01/17
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