"Private Applicator Permit Application" - New Hampshire

Private Applicator Permit Application is a legal document that was released by the New Hampshire Department of Agriculture, Markets & Food - a government authority operating within New Hampshire.

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NH DEPARTMENT OF AGRICULTURE, MARKETS & FOOD
FEE: $20
Division of Pesticide Control
NON-REFUNDABLE
P.O. Box 2042, Concord, NH 03302-2042
(603) 271-3550
PRIVATE APPLICATOR PERMIT APPLICATION
1. REGISTRATION TYPE
Restricted Use
(please check two)
Initial
General Use
2. APPLICANT’S NAME
HOME PHONE
WORK PHONE
3. MAILING ADDRESS (STREET)
(TOWN)
(STATE)
(ZIP)
4. LEGAL RESIDENCE (STREET)
(TOWN)
(STATE)
(ZIP)
5. IF YOU A RE A NON-RESIDENT OF NE W HAMPSHIRE, FURNISH THE NAME AND ADDRESS OF A PERSON
WHOSE DOMICILE IS IN THE STATE OF NEW HAMPSHIRE AND WHO IS AUTHORIZED TO RECEIVE AND
ACCEPT SERVICES OF SUMMONSES AND LEGAL NOTICES OF ALL KINDS ON YOUR BEHALF.
NAME OF LEGAL REPRESENTATIVE
ADDRESS OF LEGAL REPRESENTATIVE
*CHECK HERE IF YOU ARE A NEW HAMPSHIRE RESIDENT:
6.
NAME OF PROPERTIES WHERE
PESTICIDES ARE APPLIED
TOWN
CROP
ACRES
(PLEASE COMPLETE OTHER SIDE)
NH DEPARTMENT OF AGRICULTURE, MARKETS & FOOD
FEE: $20
Division of Pesticide Control
NON-REFUNDABLE
P.O. Box 2042, Concord, NH 03302-2042
(603) 271-3550
PRIVATE APPLICATOR PERMIT APPLICATION
1. REGISTRATION TYPE
Restricted Use
(please check two)
Initial
General Use
2. APPLICANT’S NAME
HOME PHONE
WORK PHONE
3. MAILING ADDRESS (STREET)
(TOWN)
(STATE)
(ZIP)
4. LEGAL RESIDENCE (STREET)
(TOWN)
(STATE)
(ZIP)
5. IF YOU A RE A NON-RESIDENT OF NE W HAMPSHIRE, FURNISH THE NAME AND ADDRESS OF A PERSON
WHOSE DOMICILE IS IN THE STATE OF NEW HAMPSHIRE AND WHO IS AUTHORIZED TO RECEIVE AND
ACCEPT SERVICES OF SUMMONSES AND LEGAL NOTICES OF ALL KINDS ON YOUR BEHALF.
NAME OF LEGAL REPRESENTATIVE
ADDRESS OF LEGAL REPRESENTATIVE
*CHECK HERE IF YOU ARE A NEW HAMPSHIRE RESIDENT:
6.
NAME OF PROPERTIES WHERE
PESTICIDES ARE APPLIED
TOWN
CROP
ACRES
(PLEASE COMPLETE OTHER SIDE)
7. A)
LIST THE NAMES AND ADDRESSES OF THE OWNERS, OFFICERS, OR TRUSTEES OF THE ENTITY APPLYING
PESTICIDES, WHETHER OR NOT THE ENTITY IS INCORPORATED.
NAME
ADDRESS
B)
LIST THE NAMES AND ADDRESS OF THE PERSONS CHARGED WITH RESPONSIBILITY FOR THE
APPLICATION OF PESTICIDES.
NAME
ADDRESS
8. IN ACCEPTING THIS PERMIT THE APPLICANT AGREES:
A) TO FOLLOW EXPLICITLY ALL INSTRUCTIONS OUTLINED ON THE MANUFACTURER’S CURRENT LABELING.
ST
B) TO RE PORT ALL P ESTICIDES USED EACH YEAR TO THE DIVISION BY DECEMBER 1
. IF THE USAGE
REPORT IS NOT ATTACHED, BUT IS BEING SUBMITTED BY SOMEONE OTHER THAN YOURSELF,
INDICATE THEIR NAME HERE
C) THAT FALSIFICATION OF ANY INFORMATION ON THIS APPLICATION MAY BE GROUNDS FOR DENIAL OF A
PERMIT.
PRINT NAME
SIGNATURE OF APPLICANT
DATE
NOTE: NO PERMITS WILL BE ISSUED UNLESS SECTIONS1-8 ARE FILLED OUT COMPLETELY
AND A USAGE REPORT FORM HAS BEEN SUBMITTED.
REMEMBER: TO RENEW THIS PERMIT EACH AND EVERY YEAR.
TO ATTEND APPROPRIATE RECERTIFICATION SESSIONS.
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