"Application for Professional Services License - Structural Pest Control" - Alabama

Application for Professional Services License - Structural Pest Control is a legal document that was released by the Alabama Department of Agriculture and Industries - a government authority operating within Alabama.

Form Details:

  • The latest edition currently provided by the Alabama Department of Agriculture and Industries;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Alabama Department of Agriculture and Industries.

ADVERTISEMENT
ADVERTISEMENT

Download "Application for Professional Services License - Structural Pest Control" - Alabama

Download PDF

Fill PDF online

Rate (4.5 / 5) 12 votes
Print Form
Alabama Department of Agriculture and Industries
APPLICATION FOR PROFESSIONAL SERVICES LICENSE
STRUCTURAL PEST CONTROL
MAIN OFFICE
Return to:
Date:
DEPARTMENT OF AGRICULTURE & INDUSTRIES
PESTICIDE MANAGEMENT - PROFESSIONAL SERVICES
County:
1445 FEDERAL DRIVE
MONTGOMERY AL 36107-1123
AGI.ALABAMA.GOV
PHONE: 334-240-7261 FAX: 334-240-7316
ATTENTIO N:
Application for Professional Services License as required under provisions of Chapter 28, Title 2, Code of Alabama (1975) as amended.
LICENSE FEE: $175.00 PLUS $100.00 FOR EACH CATEGORY OF WORK CERTIFIED TO PERFORM.. A $50.00 DELINQUENT PENALTY
WILL BE APPLIED IF APPLICATION IS NOT RECEIVED BY NOVEMBER 6. (PENALTY does not apply to NEW BUSINESS.) EXISTING
BUSINESSES REAPPLYING FOR A LICENSE MAY BE SUBJECT TO CIVIL PENALTY PROVISIONS UP TO $3000.00 FOR PERFORMING OR
SOLICITING PROFESSIONAL SERVICES WORK WITHOUT A LICENSE.
IF APPLICATION IS SUBMITTED WITH OTHER LICENSE FEES, PLEASE SUBMIT SEPARATE CHECKS.
CHECK CERTIFIED CATEGORY(IES) BELOW:
Household, institutional & industrial Pest Control (HPC)
Fumigation Pest Control (FC)
Control and/or Eradication of Wood Destroying Organisms (WDC)
NAME OF BUSINESS:
!!CALL TO VERIFY NAME IS AVAILABLE!!
LOCATION:
PHONE:
(
)
ZIP CODE:
PHONE:
MAILING ADDRESS:
(
)
ZIP CODE:
E-MAIL ADDRESS:
FAX #
(
)
OUT OF BUSINESS
NEW BUSINESS
ADD-ON CATEGORY to License #
RENEWAL
BUY OUT
New Address
NAME CHANGE - OLD BUSINESS NAME:
LIST CERTIFIED SUPERVISOR(S) Additional names can be attached for those that passed exams and are certified. No
additional fees are required. The Certified Operator is responsible for work performed by licensee.
EXPIRATION
COMMERCIAL
CERTIFICATION
LEGAL NAME
LAST 4 SS #
DOB
DATE
CATEGORY
CERTIFICATION #
***THIS INFORMATION APPLIES TO NEW & EXISTING BUSINESSES***
INSURANCE (HPC/WDC/FC) BOND FOR WDC ONLY!
(IF HPC/FC/WDC, attach copy of CERTIFICATE OF INSURANCE. IF WDC
INSURANCE EXPIRATION DATE:
ATTACH AN ORIGINAL SURETY BOND and copy of CONTRACTS.
SURETY BOND EXPIRATION DATE:
APPLICANT WILL ENGAGE IN BUSINESS AS:
Sole Owner
Partnership
Corporation* *
* * Corporation must be filed w/ the Secretary of State. -- must verify company name w/Dept. of Agriculture first!!
SIGNATU R E:
TITLE:
APPLIC ATI ON MUST BE SIGNED. PLEASE MAKE CHECK PAYABL E TO THE ALAB AMA DEPT OF AGRICUL TU R E
***************************
FOR OFFICE USE ONLY - DO NOT WRITE BELOW THIS LINE******************************
License Fee:
LICENSE NUMBER
:
Category Fee(s):
AGRICULTURE OFFICE STAFF USE:
Penalty:
Contract(s) Approved: Yes
No
Total:
Insurance Up-to-date:
Yes
No
Date Processed:
#
Bond Received:
Yes
No
Cash
Check
MO
Print Form
Alabama Department of Agriculture and Industries
APPLICATION FOR PROFESSIONAL SERVICES LICENSE
STRUCTURAL PEST CONTROL
MAIN OFFICE
Return to:
Date:
DEPARTMENT OF AGRICULTURE & INDUSTRIES
PESTICIDE MANAGEMENT - PROFESSIONAL SERVICES
County:
1445 FEDERAL DRIVE
MONTGOMERY AL 36107-1123
AGI.ALABAMA.GOV
PHONE: 334-240-7261 FAX: 334-240-7316
ATTENTIO N:
Application for Professional Services License as required under provisions of Chapter 28, Title 2, Code of Alabama (1975) as amended.
LICENSE FEE: $175.00 PLUS $100.00 FOR EACH CATEGORY OF WORK CERTIFIED TO PERFORM.. A $50.00 DELINQUENT PENALTY
WILL BE APPLIED IF APPLICATION IS NOT RECEIVED BY NOVEMBER 6. (PENALTY does not apply to NEW BUSINESS.) EXISTING
BUSINESSES REAPPLYING FOR A LICENSE MAY BE SUBJECT TO CIVIL PENALTY PROVISIONS UP TO $3000.00 FOR PERFORMING OR
SOLICITING PROFESSIONAL SERVICES WORK WITHOUT A LICENSE.
IF APPLICATION IS SUBMITTED WITH OTHER LICENSE FEES, PLEASE SUBMIT SEPARATE CHECKS.
CHECK CERTIFIED CATEGORY(IES) BELOW:
Household, institutional & industrial Pest Control (HPC)
Fumigation Pest Control (FC)
Control and/or Eradication of Wood Destroying Organisms (WDC)
NAME OF BUSINESS:
!!CALL TO VERIFY NAME IS AVAILABLE!!
LOCATION:
PHONE:
(
)
ZIP CODE:
PHONE:
MAILING ADDRESS:
(
)
ZIP CODE:
E-MAIL ADDRESS:
FAX #
(
)
OUT OF BUSINESS
NEW BUSINESS
ADD-ON CATEGORY to License #
RENEWAL
BUY OUT
New Address
NAME CHANGE - OLD BUSINESS NAME:
LIST CERTIFIED SUPERVISOR(S) Additional names can be attached for those that passed exams and are certified. No
additional fees are required. The Certified Operator is responsible for work performed by licensee.
EXPIRATION
COMMERCIAL
CERTIFICATION
LEGAL NAME
LAST 4 SS #
DOB
DATE
CATEGORY
CERTIFICATION #
***THIS INFORMATION APPLIES TO NEW & EXISTING BUSINESSES***
INSURANCE (HPC/WDC/FC) BOND FOR WDC ONLY!
(IF HPC/FC/WDC, attach copy of CERTIFICATE OF INSURANCE. IF WDC
INSURANCE EXPIRATION DATE:
ATTACH AN ORIGINAL SURETY BOND and copy of CONTRACTS.
SURETY BOND EXPIRATION DATE:
APPLICANT WILL ENGAGE IN BUSINESS AS:
Sole Owner
Partnership
Corporation* *
* * Corporation must be filed w/ the Secretary of State. -- must verify company name w/Dept. of Agriculture first!!
SIGNATU R E:
TITLE:
APPLIC ATI ON MUST BE SIGNED. PLEASE MAKE CHECK PAYABL E TO THE ALAB AMA DEPT OF AGRICUL TU R E
***************************
FOR OFFICE USE ONLY - DO NOT WRITE BELOW THIS LINE******************************
License Fee:
LICENSE NUMBER
:
Category Fee(s):
AGRICULTURE OFFICE STAFF USE:
Penalty:
Contract(s) Approved: Yes
No
Total:
Insurance Up-to-date:
Yes
No
Date Processed:
#
Bond Received:
Yes
No
Cash
Check
MO