"Application for Professional Services License" - Alabama

Application for Professional Services License 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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Alabama Department of Agriculture and Industries APPLICATION
FOR PROFESSIONAL SERVICES LICENSE
STRUCTURAL PEST CONTROL
SUB-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: $50.00 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:
PHONE:
***SUB-OFFICE
(
)
LOCATION:
ZIP CODE:
FAX #:
MAILING ADDRESS:
(
)
ZIP CODE:
EMAIL ADDRESS:
PHONE:
SUPERVISING OFFICE
(
)
LOCATION:
ZIP CODE:
***NOTE:
A Sub-Office must have less than three (3) employees and must not be more than 100 ro ad miles from either a Branch Office or Main
Office of the firm.
RENEWAL
NEW BUSINESS
ADD-ON CATEGORY to LICENSE #
OUT OF BUSINESS
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.
CERTIFICATION
EXPIRATION
COMMERCIAL
LEGAL NAME
LAST 4 SS #
DOB
CATEGORY
DATE
CERTIFICATION #
SEE MAIN OFFICE APPLICATION FOR INSURANCE AND/OR BOND INFORMATION
APPLICANT WILL ENGAGE IN BUSINESS AS:
Sole Owner
Partnership
Corporation* *
SIGNATU R E:
TITLE:
APPLICATI ON MUST BE SIGNED. PLEASE MAKE CHECK PAYABL E TO THE ALABAMA DEPT OF AGRICUL TURE
***************************
FOR OFFICE USE ONLY - DO NOT WRITE BELOW THIS LINE******************************
License Fee:
Category Fee(s):
LICENSE NUMBER
:
Penalty: Total:
Date Processed:
#
MO
Cash
Check
Print Form
Alabama Department of Agriculture and Industries APPLICATION
FOR PROFESSIONAL SERVICES LICENSE
STRUCTURAL PEST CONTROL
SUB-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: $50.00 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:
PHONE:
***SUB-OFFICE
(
)
LOCATION:
ZIP CODE:
FAX #:
MAILING ADDRESS:
(
)
ZIP CODE:
EMAIL ADDRESS:
PHONE:
SUPERVISING OFFICE
(
)
LOCATION:
ZIP CODE:
***NOTE:
A Sub-Office must have less than three (3) employees and must not be more than 100 ro ad miles from either a Branch Office or Main
Office of the firm.
RENEWAL
NEW BUSINESS
ADD-ON CATEGORY to LICENSE #
OUT OF BUSINESS
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.
CERTIFICATION
EXPIRATION
COMMERCIAL
LEGAL NAME
LAST 4 SS #
DOB
CATEGORY
DATE
CERTIFICATION #
SEE MAIN OFFICE APPLICATION FOR INSURANCE AND/OR BOND INFORMATION
APPLICANT WILL ENGAGE IN BUSINESS AS:
Sole Owner
Partnership
Corporation* *
SIGNATU R E:
TITLE:
APPLICATI ON MUST BE SIGNED. PLEASE MAKE CHECK PAYABL E TO THE ALABAMA DEPT OF AGRICUL TURE
***************************
FOR OFFICE USE ONLY - DO NOT WRITE BELOW THIS LINE******************************
License Fee:
Category Fee(s):
LICENSE NUMBER
:
Penalty: Total:
Date Processed:
#
MO
Cash
Check