"Application for Reciprocal Commercial Pesticide Applicator Certification" - Alabama

Application for Reciprocal Commercial Pesticide Applicator Certification 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 RECIPROCAL COMMERCIAL PESTICIDE APPLICATOR CERTIFICATION
To become a Commercial Pesticide Applicator in Alabama by reciprocity, the following information
is required:
1.
COMPLETE ENCLOSED APPLICATION.
2.
FRONT AND BACK copy of your certification credentials from certifying state (Florida,
Georgia, Indiana, Louisiana, Mississippi, Ohio, South Carolina or Tennessee) showing
expiration date and categories in which you are certified.
NOTE:
Reciprocal fee(s) as outlined on the application.
General Standards/CORE (GS) is
3.
required for all categories except Wood Treatment (WT), Tributyltin (TBT), Ornamental and
Turf Pest Control (OTPS), and Right-of-Way Pest control (ROW).
4.
The Mode of Application (Ground and/or Aerial) must be certified as well, unless otherwise
noted.
PLEASE MAKE CHECK PAYABLE TO: ALABAMA DEPARTMENT OF AGRICULTURE & INDUSTRIES.
ALABAMA DEPARTMENT OF AGRICULTURE & INDUSTRIES
RETURN TO:
PESTICIDE MANAGEMENT DIVISION, CERTIFICATION OFFICE
1445 FEDERAL DRIVE
MONTGOMERY, AL 36107-1123
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 RECIPROCAL COMMERCIAL PESTICIDE APPLICATOR CERTIFICATION
To become a Commercial Pesticide Applicator in Alabama by reciprocity, the following information
is required:
1.
COMPLETE ENCLOSED APPLICATION.
2.
FRONT AND BACK copy of your certification credentials from certifying state (Florida,
Georgia, Indiana, Louisiana, Mississippi, Ohio, South Carolina or Tennessee) showing
expiration date and categories in which you are certified.
NOTE:
Reciprocal fee(s) as outlined on the application.
General Standards/CORE (GS) is
3.
required for all categories except Wood Treatment (WT), Tributyltin (TBT), Ornamental and
Turf Pest Control (OTPS), and Right-of-Way Pest control (ROW).
4.
The Mode of Application (Ground and/or Aerial) must be certified as well, unless otherwise
noted.
PLEASE MAKE CHECK PAYABLE TO: ALABAMA DEPARTMENT OF AGRICULTURE & INDUSTRIES.
ALABAMA DEPARTMENT OF AGRICULTURE & INDUSTRIES
RETURN TO:
PESTICIDE MANAGEMENT DIVISION, CERTIFICATION OFFICE
1445 FEDERAL DRIVE
MONTGOMERY, AL 36107-1123
www.agi.alabama.gov
“We provide employment & services without discrimination.”
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 RECIPROCAL COMMERCIAL PESTICIDE APPLICATOR CERTIFICATION
CHECK ONE
FIRST application for Alabama Pesticide Certification. Attach copy of current permit FRONT & BACK from certifying state (Florida,
Georgia, Indiana, Louisiana, Mississippi, Ohio, South Carolina or Tennessee).
ADD-ON category to current permit.
RENEW previous reciprocated categories. Current Alabama Permit Number is?
XXX - XX -
Legal Name
SSN
Date of Birth
Home Address
City
County
State
Zip
(
)
-
(
)
-
PO Box
City
State
Zip
Phone 1:
Phone 2:
(
)
-
Present Employer
Phone
-
Address
City
State
Zip
-
PO Box
City
State
Zip
E-Mail
OPERATIONAL CATEGORIES CHECK ONLY THE CATEGORIES FOR WHICH YOU ARE REQUESTING RECIPROCAL
CERTIFICATION (Include General Standards and Mode of Application unless otherwise noted).
CATEGORIES:
Mode of Application NOT required for these following
categories. -- General Standards is required.
General Standards (CORE) (GS)
75.00
Mode of Application: (CHECK ONE)
CATEGORIES:
Aerial Equipment (AIR)
120.00
Ag. Commodity Fumigation (ACF)
120.00
120.00
120.00
Ground Equipment (GRND)
Agricultural Animal Pest Control (AA)
Demonstration & Research (D&R)
120.00
Certification for General Standards and Mode of
Regulatory (REG)
120.00
Application are required for the following categories
*Unless otherwise noted.
General Standards and Mode of Application are NOT
required for these following categories.
Agricultural Plant Pest Control (AP)
120.00
Aquatic Pest Control (AQ)
120.00
Forest Pest Control (FOR)
120.00
Metam Sewer (MS)
120.00
120.00
120.00
Public Health Pest Control (PH)
Ornamental & Turf Pest Control (OTPS)
Tributylin (TBT)
120.00
*General Standards NOT required for:
Wood Treatment (WT)
120.00
Right-of-Way Pest Control (ROW)
120.00
FEE
APPLICATION
FOR EACH CATEGORY CHECKED MUST ACCOMPANY THIS
.
I certify that the above information is correct:
TO:
PLEASE MAKE CHECK PAYABLE
AL. DEPT OF AGRICULTURE & INDUSTRIES.
RETURN TO:
ALABAMA DEPARTMENT OF AGRICULTURE & INDUSTRIES
Signature of Applicant
PESTICIDE MANAGEMENT DIVISION, CERTIFICATION OFFICE
1445 FEDERAL DRIVE
MONTGOMERY, AL 36107-1123
Date of Application
DO NOT WRITE BELOW THIS LINE
No.
Check #
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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