"Application for Commercial Pesticide Applicator Permit (Renewal)" - Alabama

Application for Commercial Pesticide Applicator Permit (Renewal) 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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S
A
TATE OF
LABAMA
D
A
I
EPARTMENT OF
GRICULTURE AND
NDUSTRIES
Pesticide Management - Certification Unit
1445 Federal Drive • Montgomery, Alabama 36107-1123
(334) 240-7240 • 1-800-642-7761, Ext. 7240
John McMillan
Commissioner
APPLICATION FOR
COMMERCIAL PESTICIDE APPLICATOR PERMIT
FOR:
PERMIT #
EXPIRATION DATE:
RENEWAL/Expired
I understand and will comply with the provisions of the below laws and rules, as well as product label instructions. Further I understand that any violation
of the laws, rules, or label instructions constitutes grounds for suspension or revocation of the permit and other penalties.
XXX - XX -
Legal Name
SSN
Date of Birth
Home Address
City
County
State
Zip
(
)
-
(
)
-
PO Box
City
State
Zip
Phone 1:
Phone 2:
(
)
-
Employer
Phone
-
Address
City
State
Zip
-
PO Box
City
State
Zip
E-Mail
I hereby apply for a permit as a Commercial Pesticide Applicator to
I hereby apply for a permit as a Commercial Pesticide Applicator to
purchase and use pesticides Pursuant to CHAPTER 27, TITLE 2, CODE
purchase and use pesticides Pursuant to CHAPTER 28, TITLE 2. CODE
OF ALABAMA (1975) and CHAPTER 80-1-13,
OF ALABAMA (I 975) and CHAPTER 80-1-13,
ALABAMA ADMINISTRATIVE CODE.
ALABAMA ADMINISTRATIVE CODE.
Certification Requested in Category(ies):
Certification Requested in Category(ies):
Household Pest Control (HPC)
Ag. Commodity Fumigation (ACF)
Agricultural Animal Pest Control (AA)
Wood Destroying Organisms (WDC)
Agricultural Plant Pest Control (AP)
Fumigation Pest Control (FC)
Aerial Equipment (AIR)
Ornamental & Turf Pest Control/
Ground Equipment (GRND)
Supervisor (OTPS)
Aquatic Pest Control (AQ)
Household Pest Control (HPB)
Biocides (BIO)
Wood Destroying Organisms (WDS)
Demonstration & Research (D&R)
Fumigation Pest Control (FB)
Forest Pest Control (FOR)
Public Health Pest Control (PH)
CUSTODIAL CATEGORIES:
Metam Sewer (MS)
Ornamental & Turf/CUSTODIAL (OTPC)
Regulatory (REG)
Industrial, Institutional & Health-
Right-of-Way Pest Control (ROW)
Related/CUSTODIAL (IIHC)
Seed Treatment (ST)
RECERTIFICATION FOR EXPIRED PERMIT:
Tributylin (TBT)
Wood Treatment (WT)
/
/
Date Passed Recertification Exam.
P
F
$45.00
ERMIT
EE
APPLICATION
FOR EACH CATEGORY MUST ACCOMPANY THIS
.
TO:
PLEASE MAKE CHECK PAYABLE
AL DEPT OF AGRICULTURE & INDUSTRIES
RETURN TO:
DEPARTMENT OF AGRICULTURE & INDUSTRIES
PESTICIDE MANAGEMENT--CERTIFICATION UNIT
1445 FEDERAL DRIVE
MONTGOMERY, AL 36107-1123
Signature of Applicant
DO NOT WRITE BELOW THIS LINE
Check #
No.
Amount Paid:
Certification Permit
Expiration Date:
Date Issued:
www.agi.alabama.gov
“We provide employment & services without discrimination.”
Print Form
S
A
TATE OF
LABAMA
D
A
I
EPARTMENT OF
GRICULTURE AND
NDUSTRIES
Pesticide Management - Certification Unit
1445 Federal Drive • Montgomery, Alabama 36107-1123
(334) 240-7240 • 1-800-642-7761, Ext. 7240
John McMillan
Commissioner
APPLICATION FOR
COMMERCIAL PESTICIDE APPLICATOR PERMIT
FOR:
PERMIT #
EXPIRATION DATE:
RENEWAL/Expired
I understand and will comply with the provisions of the below laws and rules, as well as product label instructions. Further I understand that any violation
of the laws, rules, or label instructions constitutes grounds for suspension or revocation of the permit and other penalties.
XXX - XX -
Legal Name
SSN
Date of Birth
Home Address
City
County
State
Zip
(
)
-
(
)
-
PO Box
City
State
Zip
Phone 1:
Phone 2:
(
)
-
Employer
Phone
-
Address
City
State
Zip
-
PO Box
City
State
Zip
E-Mail
I hereby apply for a permit as a Commercial Pesticide Applicator to
I hereby apply for a permit as a Commercial Pesticide Applicator to
purchase and use pesticides Pursuant to CHAPTER 27, TITLE 2, CODE
purchase and use pesticides Pursuant to CHAPTER 28, TITLE 2. CODE
OF ALABAMA (1975) and CHAPTER 80-1-13,
OF ALABAMA (I 975) and CHAPTER 80-1-13,
ALABAMA ADMINISTRATIVE CODE.
ALABAMA ADMINISTRATIVE CODE.
Certification Requested in Category(ies):
Certification Requested in Category(ies):
Household Pest Control (HPC)
Ag. Commodity Fumigation (ACF)
Agricultural Animal Pest Control (AA)
Wood Destroying Organisms (WDC)
Agricultural Plant Pest Control (AP)
Fumigation Pest Control (FC)
Aerial Equipment (AIR)
Ornamental & Turf Pest Control/
Ground Equipment (GRND)
Supervisor (OTPS)
Aquatic Pest Control (AQ)
Household Pest Control (HPB)
Biocides (BIO)
Wood Destroying Organisms (WDS)
Demonstration & Research (D&R)
Fumigation Pest Control (FB)
Forest Pest Control (FOR)
Public Health Pest Control (PH)
CUSTODIAL CATEGORIES:
Metam Sewer (MS)
Ornamental & Turf/CUSTODIAL (OTPC)
Regulatory (REG)
Industrial, Institutional & Health-
Right-of-Way Pest Control (ROW)
Related/CUSTODIAL (IIHC)
Seed Treatment (ST)
RECERTIFICATION FOR EXPIRED PERMIT:
Tributylin (TBT)
Wood Treatment (WT)
/
/
Date Passed Recertification Exam.
P
F
$45.00
ERMIT
EE
APPLICATION
FOR EACH CATEGORY MUST ACCOMPANY THIS
.
TO:
PLEASE MAKE CHECK PAYABLE
AL DEPT OF AGRICULTURE & INDUSTRIES
RETURN TO:
DEPARTMENT OF AGRICULTURE & INDUSTRIES
PESTICIDE MANAGEMENT--CERTIFICATION UNIT
1445 FEDERAL DRIVE
MONTGOMERY, AL 36107-1123
Signature of Applicant
DO NOT WRITE BELOW THIS LINE
Check #
No.
Amount Paid:
Certification Permit
Expiration Date:
Date Issued:
www.agi.alabama.gov
“We provide employment & services without discrimination.”
A
S
of
TATE
LABAMA
D
A
I
EPARTMENT OF
GRICULTURE A ND
NDUSTRIES
Pesticide Man agement – Cert ification Unit
1445 Federal Drive
Montgomery, Alabama 36107-1123
(334) 240-240-7240
1-800-642-7761, Ext. 7240
John McMillan
Commissioner
ALABAMA DEPARTMENT OF AGRICULTURE AND INDUSTRIES
DECLARATION OF CITIZENSHIP OR LEGAL STATUS FOR INDIVIDUALS SEEKING
PUBLIC BENEFITS
As of January 1, 2012, Section 7 of the BEASON-HAMMON ALABAMA TAXPAYER AND
CITIZEN PROTECTION ACT (the ''Act''), Act No. 2011-535, requires that the Alabama Department of
Agriculture & Industries (''ADAI'') obtain a declaration from any person applying for a ''state or local
public benefit,'' as that term is defined in 8 U.S.C. § 1621, that said person is a United States Citizen or an
Alien lawfully present in the United States. 8 U.S.C § 1621 (c) (A) defines ''state or local benefit'' as:
''Any grant, contract, loan, professional license, or commercial license provided by an agency of a State
or local government or by appropriated funds of a State or local government..."
Sections 7 (h) and (i) of the Act provide that any person who knowingly makes a false,
fictitious, or fraudulent statement or representation in a declaration regarding citizenship or lawful status
shall be guilty of perjury in the second degree pursuant to section 13A-10-102, Code of Alabama 1975.
As a result, you must complete and sign the following declaration before ADAI can issue your
license, permit, or certification:
I, ___
_____________ (print your name), declare under penalty of perjury, that
I am a United States Citizen or an alien lawfully present in the United States.
____________________________________________ _________________________________________
Signature
Date
www.agi.alabama.gov
“We provide employment & services without discrimination.”
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