"Application for Restricted Use Pesticide Certification" - Nevada

Application for Restricted Use Pesticide Certification is a legal document that was released by the Nevada Department of Agriculture - a government authority operating within Nevada.

Form Details:

  • Released on March 1, 2016;
  • The latest edition currently provided by the Nevada Department of Agriculture;
  • 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 printable version of the form by clicking the link below or browse more documents and templates provided by the Nevada Department of Agriculture.

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NEVADA DEPARTMENT OF AGRICULTURE
st
405 S. 21
St.
2300 E. St. Louis Ave.
4780 E. Idaho St.
Sparks, Nevada 89431
Las Vegas, Nevada 89104
Elko, NV 89801
(775) 353-3712
(702) 668-4590
(775) 738-8076
APPLICATION FOR RESTRICTED USE PESTICIDE CERTIFICATION
st
1
Time certifying
Re-certifying by Exam
Adding Category(ies)
Re-certifying by CEU’s
(attach proof of required CEU’s (12 total w/ at
least 2 CEU’s in Law)
Applicant: _____________________________________________________________
Test Date:___________________
Last Name
First Name
M.I.
Mailing Address: ____________________________________________________________________________________
Street or PO Box
City
State
Zip Code
Business Address: ___________________________________________________________________________________
Home Address: ______________________________________________________________________________________
DBA/Employed by: ___________________________________________________________________________________
Company/Employer’s Name
Company Address
Home Phone: (______) _________________
E-mail: _______________________@_________________________
Business Phone: (_____) ____________________
Non-Primary Principal Commercial
Private Applicator
Applied
Category Code
Description
Score
Applied
Category Code
Description
Score
General Examination
____
General Examination
____
A
Agriculture Spanish Exam
____
A
Agriculture Spanish Exam
____
D
O and T Spanish Exam
____
D
O and T Spanish Exam
____
A
Agricultural Plant
____
Agriculture pest control:
B
Agricultural Animal
____
A
Plant:
____
C
Forestry
____
Forage, grain, pasture and range
D
Ornamental and Turf
____
Row crops
E
Seed Treatment
____
F
Aquatic
____
Seed crops
G
Right of Way
____
B
Animal:
____
H
Industrial
____
Dairy animal pest control
I
Institutional
____
Meat animal pest control
J
Structural
____
Poultry pest control
K
Public Health
____
Specialty Crops:
L1
Commodity fumigation
____
F
Aquatic
____
L2
Rodent burrow fumigation
____
R
Nursery & Greenhouse
____
L3
Soil fumigation**
____
**
must complete an approved EPA training course
H
Industrial Farm
____
L4
Structural fumigation
____
D
Ornamental and Turf
____
M
Mosquito
____
R
Nursery and Greenhouse
____
C
Forestry & Rangeland
____
O
Wood Preservatives
____
L1 Commodity fumigation
____
N
Predatory (USDA-WS only)
____
L2 Rodent burrow fumigation
____
P
M-44 (USDA-WS only)
____
U
Chemigation
____
L3 Soil fumigation
____
S
Metam-Sodium
____
U
Chemigation
____
Expiration
Number
Test / Re-certification Location
Fee
Receipt Number
rev. 3-16
NEVADA DEPARTMENT OF AGRICULTURE
st
405 S. 21
St.
2300 E. St. Louis Ave.
4780 E. Idaho St.
Sparks, Nevada 89431
Las Vegas, Nevada 89104
Elko, NV 89801
(775) 353-3712
(702) 668-4590
(775) 738-8076
APPLICATION FOR RESTRICTED USE PESTICIDE CERTIFICATION
st
1
Time certifying
Re-certifying by Exam
Adding Category(ies)
Re-certifying by CEU’s
(attach proof of required CEU’s (12 total w/ at
least 2 CEU’s in Law)
Applicant: _____________________________________________________________
Test Date:___________________
Last Name
First Name
M.I.
Mailing Address: ____________________________________________________________________________________
Street or PO Box
City
State
Zip Code
Business Address: ___________________________________________________________________________________
Home Address: ______________________________________________________________________________________
DBA/Employed by: ___________________________________________________________________________________
Company/Employer’s Name
Company Address
Home Phone: (______) _________________
E-mail: _______________________@_________________________
Business Phone: (_____) ____________________
Non-Primary Principal Commercial
Private Applicator
Applied
Category Code
Description
Score
Applied
Category Code
Description
Score
General Examination
____
General Examination
____
A
Agriculture Spanish Exam
____
A
Agriculture Spanish Exam
____
D
O and T Spanish Exam
____
D
O and T Spanish Exam
____
A
Agricultural Plant
____
Agriculture pest control:
B
Agricultural Animal
____
A
Plant:
____
C
Forestry
____
Forage, grain, pasture and range
D
Ornamental and Turf
____
Row crops
E
Seed Treatment
____
F
Aquatic
____
Seed crops
G
Right of Way
____
B
Animal:
____
H
Industrial
____
Dairy animal pest control
I
Institutional
____
Meat animal pest control
J
Structural
____
Poultry pest control
K
Public Health
____
Specialty Crops:
L1
Commodity fumigation
____
F
Aquatic
____
L2
Rodent burrow fumigation
____
R
Nursery & Greenhouse
____
L3
Soil fumigation**
____
**
must complete an approved EPA training course
H
Industrial Farm
____
L4
Structural fumigation
____
D
Ornamental and Turf
____
M
Mosquito
____
R
Nursery and Greenhouse
____
C
Forestry & Rangeland
____
O
Wood Preservatives
____
L1 Commodity fumigation
____
N
Predatory (USDA-WS only)
____
L2 Rodent burrow fumigation
____
P
M-44 (USDA-WS only)
____
U
Chemigation
____
L3 Soil fumigation
____
S
Metam-Sodium
____
U
Chemigation
____
Expiration
Number
Test / Re-certification Location
Fee
Receipt Number
rev. 3-16