"Application Form for Professional Services License - Structural Pest Control Branch Office" - Alabama

Application Form for Professional Services License - Structural Pest Control Branch Office 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
BRANCH 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: $75.00 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 (WDS)
NAME OF BUSINESS:
BRANCH LOCATION:
PHONE:
(
)
ZIP CODE:
MAILING ADDRESS:
FAX #:
(
)
ZIP CODE:
EMAIL ADDRESS:
PHONE:
MAIN OFFICE
(
)
LOCATION:
ZIP CODE:
NEW BUSINESS
OUT OF BUSINESS
BUY OUT
ADD-ON CATEGORY to License #
RENEWAL
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.
COMMERCIAL
CERTIFICATION
EXPIRATION
LAST 4 SS #
LEGAL NAME
DOB
CERTIFICATION #
CATEGORY
DATE
***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:
SIGNATURE:
TITLE:
APPLICATION MUST BE SIGNED. PLEASE MAKE CHECK PAYABLE TO THE ALABAMA DEPT OF AGRICULTURE
***************************
FOR OFFICE USE ONLY - DO NOT WRITE BELOW THIS LINE******************************
License Fee:
Category Fee(s):
LICENSE NUMBER
:
AGRICULTURE OFFICE STAFF USE:
Penalty:
Contract(s) Approved: Yes
No
Total:
Insurance Up-to-date:
Yes
No
Date Processed:
#
Cash
Check
MO
Bond Received:
Yes
No
Print Form
Alabama Department of Agriculture and Industries
APPLICATION FOR PROFESSIONAL SERVICES LICENSE
STRUCTURAL PEST CONTROL
BRANCH 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: $75.00 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 (WDS)
NAME OF BUSINESS:
BRANCH LOCATION:
PHONE:
(
)
ZIP CODE:
MAILING ADDRESS:
FAX #:
(
)
ZIP CODE:
EMAIL ADDRESS:
PHONE:
MAIN OFFICE
(
)
LOCATION:
ZIP CODE:
NEW BUSINESS
OUT OF BUSINESS
BUY OUT
ADD-ON CATEGORY to License #
RENEWAL
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.
COMMERCIAL
CERTIFICATION
EXPIRATION
LAST 4 SS #
LEGAL NAME
DOB
CERTIFICATION #
CATEGORY
DATE
***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:
SIGNATURE:
TITLE:
APPLICATION MUST BE SIGNED. PLEASE MAKE CHECK PAYABLE TO THE ALABAMA DEPT OF AGRICULTURE
***************************
FOR OFFICE USE ONLY - DO NOT WRITE BELOW THIS LINE******************************
License Fee:
Category Fee(s):
LICENSE NUMBER
:
AGRICULTURE OFFICE STAFF USE:
Penalty:
Contract(s) Approved: Yes
No
Total:
Insurance Up-to-date:
Yes
No
Date Processed:
#
Cash
Check
MO
Bond Received:
Yes
No