"Request for Change of Information for Custom Pesticide Applicators" - Alabama

Request for Change of Information for Custom Pesticide Applicators is a legal document that was released by the Alabama Department of Agriculture and Industries - a government authority operating within Alabama.

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Download "Request for Change of Information for Custom Pesticide Applicators" - Alabama

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Print Form
State of Alabama Department of Agriculture & Industries
Pesticide Management Section
1445 Federal Drive
Montgomery, AL 36107
Telephone: (334) 240-7286 Fax: (334) 240-7168
REQUEST FOR CHANGE OF INFORMATION
FOR CUSTOM PESTICIDE APPLICATORS
Complete your Firm name and permit information plus other sections as needed to update your file.
Check Categories listed on Current or Most Recent Permit
Permit Type:
Agricultural Animal Pest Control (AA)
Demonstration & Research (D&R)
Right-of-Way Pest Control (ROW)
CUSTOM:
Agricultural Plant Pest Control (AP)
Forest Pest Control (FOR)
Seed Treatment (ST)
Current or Most
Aerial Equipment (AIR)
Public Health Pest Control (PH)
Wood Treatment (WT)
Recent permit #
P/M-
Ground Equipment (GRD)
Metam Sewer (MS)
Ag. Commodity Fumigation (ACF)
Aquatic Pest Control (AQ)
Regulatory (REG)
Previous or Old Information: Please enter your previous firm name and then only the information to be changed.
Permittee (Firm Name):
DBA
Phy. Address
City:
State:
Zip:
Mail Address:
City:
State:
Zip:
(
)
-
(
)
-
County of Location:
Office Phone:
Cell Phone:
(
)
-
Fax #:
E-Mail:
Remove Name of Certified Person # 1:
Last 4 digits of SSN:
Last Name
First
Middle
Suffix
/
/
Certification. #:
Certified Catagory(s):
Expiration date:
Remove Name of Certified Person # 2:
Last 4 digits of SSN:
Last Name
First
Middle
Suffix
/
/
Certification. #:
Certified Category(s):
Expiration date:
Categories to be deleted from Permit:
AA
AP
AIR
GRD
AQ
D&R
FOR
PH
MS
REG
ROW
ST
WT
ACF
Please complete all of the following Firm information and other information as needed in order to update your permit.
Permittee (Firm Name):
DBA
Phy. Address
City:
State:
Zip:
Mail Address:
City:
State:
Zip:
(
)
-
(
)
-
County of Location:
Office Phone:
Cell Phone:
(
)
-
Fax #:
E-Mail:
Add Name of Certified Person # 1:
Last 4 digits of SSN:
Last Name
First
Middle
Suffix
/
/
Certification. #:
Certified Category(s):
Expiration date:
Add Name of Certified Person # 2:
Last 4 digits of SSN:
Last Name
First
Middle
Suffix
/
/
Certification. #:
Certified Category(s):
Expiration date:
AA
AP
AIR
GRD
AQ
D&R
FOR
Categories to be added to Permit:
PH
MS
REG
ROW
ST
WT
ACF
Categories added to Custom Applicator Permit must be supported by proper Certification, and an application and additional fees where applicable.
By signing this form I am requesting an immediate change to the information listed above for this Permittee's
Custom Applicator Permit. I certify that all of the above listed information is true and correct to the best of my
knowledge. I also certify that I have the authority to make the above requested changes.
Last 4 digits of SSN:
Name of Person Requesting Changes:
Last Name
First
Middle
Suffix
Title of Person Requesting Changes:
Signature:
Date:
*****MUST BE SIGNED AND DATED*****
Print Form
State of Alabama Department of Agriculture & Industries
Pesticide Management Section
1445 Federal Drive
Montgomery, AL 36107
Telephone: (334) 240-7286 Fax: (334) 240-7168
REQUEST FOR CHANGE OF INFORMATION
FOR CUSTOM PESTICIDE APPLICATORS
Complete your Firm name and permit information plus other sections as needed to update your file.
Check Categories listed on Current or Most Recent Permit
Permit Type:
Agricultural Animal Pest Control (AA)
Demonstration & Research (D&R)
Right-of-Way Pest Control (ROW)
CUSTOM:
Agricultural Plant Pest Control (AP)
Forest Pest Control (FOR)
Seed Treatment (ST)
Current or Most
Aerial Equipment (AIR)
Public Health Pest Control (PH)
Wood Treatment (WT)
Recent permit #
P/M-
Ground Equipment (GRD)
Metam Sewer (MS)
Ag. Commodity Fumigation (ACF)
Aquatic Pest Control (AQ)
Regulatory (REG)
Previous or Old Information: Please enter your previous firm name and then only the information to be changed.
Permittee (Firm Name):
DBA
Phy. Address
City:
State:
Zip:
Mail Address:
City:
State:
Zip:
(
)
-
(
)
-
County of Location:
Office Phone:
Cell Phone:
(
)
-
Fax #:
E-Mail:
Remove Name of Certified Person # 1:
Last 4 digits of SSN:
Last Name
First
Middle
Suffix
/
/
Certification. #:
Certified Catagory(s):
Expiration date:
Remove Name of Certified Person # 2:
Last 4 digits of SSN:
Last Name
First
Middle
Suffix
/
/
Certification. #:
Certified Category(s):
Expiration date:
Categories to be deleted from Permit:
AA
AP
AIR
GRD
AQ
D&R
FOR
PH
MS
REG
ROW
ST
WT
ACF
Please complete all of the following Firm information and other information as needed in order to update your permit.
Permittee (Firm Name):
DBA
Phy. Address
City:
State:
Zip:
Mail Address:
City:
State:
Zip:
(
)
-
(
)
-
County of Location:
Office Phone:
Cell Phone:
(
)
-
Fax #:
E-Mail:
Add Name of Certified Person # 1:
Last 4 digits of SSN:
Last Name
First
Middle
Suffix
/
/
Certification. #:
Certified Category(s):
Expiration date:
Add Name of Certified Person # 2:
Last 4 digits of SSN:
Last Name
First
Middle
Suffix
/
/
Certification. #:
Certified Category(s):
Expiration date:
AA
AP
AIR
GRD
AQ
D&R
FOR
Categories to be added to Permit:
PH
MS
REG
ROW
ST
WT
ACF
Categories added to Custom Applicator Permit must be supported by proper Certification, and an application and additional fees where applicable.
By signing this form I am requesting an immediate change to the information listed above for this Permittee's
Custom Applicator Permit. I certify that all of the above listed information is true and correct to the best of my
knowledge. I also certify that I have the authority to make the above requested changes.
Last 4 digits of SSN:
Name of Person Requesting Changes:
Last Name
First
Middle
Suffix
Title of Person Requesting Changes:
Signature:
Date:
*****MUST BE SIGNED AND DATED*****