Form SPS-13-19 "Application for Employee Registration Card" - Georgia (United States)

What Is Form SPS-13-19?

This is a legal form that was released by the Georgia Department of Agriculture - a government authority operating within Georgia (United States). As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

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

Download a printable version of Form SPS-13-19 by clicking the link below or browse more documents and templates provided by the Georgia Department of Agriculture.

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Download Form SPS-13-19 "Application for Employee Registration Card" - Georgia (United States)

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APPLICATION FOR EMPLOYEE REGISTRATION CARD
This application can be used to apply for an initial employee registration card, a
replacement card or to transfer a registration to a new employer/company. This application
must include the Designated Certified Operator signature and indicate employee
operational categories along with a $10.00 registration fee paid by check or money order
made payable to the Georgia Department of Agriculture.
Name:_________________________________________DOB:___________________
Address:_______________________________________________________________
Phone Number:_________________________________________________________
Email Address:_________________________________________________________
Currently Registered:
Yes
No
(circle one)
*If yes – Employee Registration Number:___________________________________
Employer/Company: ____________________________________________________
Company License Number:_______________________________________________
Verification of Employment
To be completed by Designated Certified Operator
I verify that the above identified employee has met all requirements of employee registration as required
by chapter 620-3-.02 of the Rules of the Georgia Structural Pest Control Act.
DCO Signature:_________________________________________Date:_____________
Print Name:________________________________ Certification Number:__________
Circle category(ies) in which employee operates:
WDO
HPC
FUM
Mail application and fee for the Employee Registration card to the following address. The
$10.00 fee can be paid by check or money order.
Georgia Department of Agriculture
Structural Pest Control Section - Room 411
19 Martin Luther King Jr. Drive
Atlanta, GA 30334-4201
SPS-13-19
APPLICATION FOR EMPLOYEE REGISTRATION CARD
This application can be used to apply for an initial employee registration card, a
replacement card or to transfer a registration to a new employer/company. This application
must include the Designated Certified Operator signature and indicate employee
operational categories along with a $10.00 registration fee paid by check or money order
made payable to the Georgia Department of Agriculture.
Name:_________________________________________DOB:___________________
Address:_______________________________________________________________
Phone Number:_________________________________________________________
Email Address:_________________________________________________________
Currently Registered:
Yes
No
(circle one)
*If yes – Employee Registration Number:___________________________________
Employer/Company: ____________________________________________________
Company License Number:_______________________________________________
Verification of Employment
To be completed by Designated Certified Operator
I verify that the above identified employee has met all requirements of employee registration as required
by chapter 620-3-.02 of the Rules of the Georgia Structural Pest Control Act.
DCO Signature:_________________________________________Date:_____________
Print Name:________________________________ Certification Number:__________
Circle category(ies) in which employee operates:
WDO
HPC
FUM
Mail application and fee for the Employee Registration card to the following address. The
$10.00 fee can be paid by check or money order.
Georgia Department of Agriculture
Structural Pest Control Section - Room 411
19 Martin Luther King Jr. Drive
Atlanta, GA 30334-4201
SPS-13-19