"Request for Change of Information for Professional Services Operators" - Alabama

Request for Change of Information for Professional Services Operators 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 Professional Services Operators" - Alabama

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S
A
TATE OF
LABAMA
D
A
I
EPARTMENT OF
GRICULTURE AND
NDUSTRIES
Pesticide Management - Professional Services
1445 Federal Drive • Montgomery, Alabama 36107-1123
(334) 240-7261 • 1-800-642-7761, Ext. 7261
John McMillan
Commissioner
REQUEST FOR CHANGE OF INFORMATION
FOR PROFESSIONAL SERVICES OPERATORS
Complete your Firm name and license information plus other sections as needed to update your file.
License Type:
Horticultural:
SLP
LD
OTPS
TS - Current or Most Recent license #PS-H -
Structural Main:
HPC
WDO
FUM -
Current or Most Recent license #PS-M-
Branch office:
HPC
WDO
FUM -
Current or Most Recent license #PS-B-
Sub-office:
HPC
WDO
FUM -
Current or Most Recent license #PS-S-
Previous or Old Information: Please enter your previous firm name and then only the information to be changed.
Licensee (Firm Name):
DBA
Phy. Address
City:
State:
Zip:
Mail Address:
City:
State:
Zip:
(
)
-
(
)
-
County of Location:
Office Phone:
Cell Phone:
(
)
-
Fax #:
E-Mail:
Last 4 digits of SSN:
Remove Name of Certified Person # 1:
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:
OTPS
TS.
HPC
WDO
FUM
SLP
LD
Structural:
Categories to be deleted from License:
Horticultural:
Please complete all of the following Firm information and other information as needed in order to update your license.
Licensee (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:
SLP
LD
OTPS
TS.
HPC
WDO
FUM
Categories to be added to License:
Horticultural:
Structural:
Categories added to a Professional Services License 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 Licensee's
Professional Services License. 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.
Name of Person Requesting Changes:
Last 4 digits of SSN:
Last Name
First
Middle
Suffix
Title of Person Requesting Changes:
Signature:
Date:
*****MUST BE SIGNED AND DATED*****
www.agi.alabama.gov
“We provide employment & services without discrimination.”
Print Form
Print Form
S
A
TATE OF
LABAMA
D
A
I
EPARTMENT OF
GRICULTURE AND
NDUSTRIES
Pesticide Management - Professional Services
1445 Federal Drive • Montgomery, Alabama 36107-1123
(334) 240-7261 • 1-800-642-7761, Ext. 7261
John McMillan
Commissioner
REQUEST FOR CHANGE OF INFORMATION
FOR PROFESSIONAL SERVICES OPERATORS
Complete your Firm name and license information plus other sections as needed to update your file.
License Type:
Horticultural:
SLP
LD
OTPS
TS - Current or Most Recent license #PS-H -
Structural Main:
HPC
WDO
FUM -
Current or Most Recent license #PS-M-
Branch office:
HPC
WDO
FUM -
Current or Most Recent license #PS-B-
Sub-office:
HPC
WDO
FUM -
Current or Most Recent license #PS-S-
Previous or Old Information: Please enter your previous firm name and then only the information to be changed.
Licensee (Firm Name):
DBA
Phy. Address
City:
State:
Zip:
Mail Address:
City:
State:
Zip:
(
)
-
(
)
-
County of Location:
Office Phone:
Cell Phone:
(
)
-
Fax #:
E-Mail:
Last 4 digits of SSN:
Remove Name of Certified Person # 1:
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:
OTPS
TS.
HPC
WDO
FUM
SLP
LD
Structural:
Categories to be deleted from License:
Horticultural:
Please complete all of the following Firm information and other information as needed in order to update your license.
Licensee (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:
SLP
LD
OTPS
TS.
HPC
WDO
FUM
Categories to be added to License:
Horticultural:
Structural:
Categories added to a Professional Services License 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 Licensee's
Professional Services License. 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.
Name of Person Requesting Changes:
Last 4 digits of SSN:
Last Name
First
Middle
Suffix
Title of Person Requesting Changes:
Signature:
Date:
*****MUST BE SIGNED AND DATED*****
www.agi.alabama.gov
“We provide employment & services without discrimination.”