Form 18 Application for Structural Pest Control License - North Carolina

Form 18 or the "Application For Structural Pest Control License" is a form issued by the North Carolina Department of Agriculture and Consumer Services.

Download a PDF version of the Form 18 down below or find it on the North Carolina Department of Agriculture and Consumer Services Forms website.

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NORTH CAROLINA DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES
STRUCTURAL PEST CONTROL & PESTICIDES DIVISION
1090 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1090
APPLICATION FOR STRUCTURAL PEST CONTROL LICENSE
(Type or Print in Ink)
APPLICANT INFORMATION
Applicant's Name:
Social Security Number:
Home Address:
Job Title
City
State
Zip
Telephone #
E-Mail Address
COMPANY INFORMATION
Company Name:
County:
Street Address
Mailing address (if different from street address)
State
Zip
County
State
Zip
County
City
City
Telephone Number:
Fax Number (if applicable):
800 Number(if applicable):
LICENSE INFORMATION
Address Change
New License:
New License Phase:
Transfer of License:
Replacement License
This application is for a: (Check the applicable
(date of transfer)
box. For transfers, indicate the last date of
employment with the previous employer.):
P (Household Pest)
W (Wood-Destroying
F (Fumigation)
Check license phases for which application is being
Organism)
made:
Active
Inactive
Indicate the status in which the license is to be issued: (If inactive,
you will not receive a license certificate at this time.)
EMPLOYEE INFORMATION
Indicate the number of employees who will perform structural pest control under the license, not
including you or clerical employees.
RESIDENT AGENT INFORMATION
If you are not a resident of North Carolina you must designate a resident agent. The resident agent's address must be the
same as the company address.
Resident Agent's Name:
Telephone Number:
Address:
City
State
Zip
County
FEES SUBMITTED
Fees for a new license are:
Fee to add a phase is:
Fee for a license transfer or
Enter total fee enclosed:
One phase:
$200.00
$75.00 for each phase.
replacement is $10.00
Two phases:
$275.00
Three phases: $350.00
INSURANCE INFORMATION
The license can not be issued without proof of insurance. Proof of insurance as required by G.S. 106-65.37 and 2 NCAC
34 .0902 must include a pollution and contamination endorsement clause. Insurance certificates are accepted from the
insurance company only.
APPLICANT AND RESIDENT AGENT CERTIFICATION
I hereby certify that the information given in this application is true and correct.
Signature of License Applicant::
Date:
Signature of Resident Agent: (required if applicable):
Date:
Form No. 18 (Revised Feb 2011)
NORTH CAROLINA DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES
STRUCTURAL PEST CONTROL & PESTICIDES DIVISION
1090 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1090
APPLICATION FOR STRUCTURAL PEST CONTROL LICENSE
(Type or Print in Ink)
APPLICANT INFORMATION
Applicant's Name:
Social Security Number:
Home Address:
Job Title
City
State
Zip
Telephone #
E-Mail Address
COMPANY INFORMATION
Company Name:
County:
Street Address
Mailing address (if different from street address)
State
Zip
County
State
Zip
County
City
City
Telephone Number:
Fax Number (if applicable):
800 Number(if applicable):
LICENSE INFORMATION
Address Change
New License:
New License Phase:
Transfer of License:
Replacement License
This application is for a: (Check the applicable
(date of transfer)
box. For transfers, indicate the last date of
employment with the previous employer.):
P (Household Pest)
W (Wood-Destroying
F (Fumigation)
Check license phases for which application is being
Organism)
made:
Active
Inactive
Indicate the status in which the license is to be issued: (If inactive,
you will not receive a license certificate at this time.)
EMPLOYEE INFORMATION
Indicate the number of employees who will perform structural pest control under the license, not
including you or clerical employees.
RESIDENT AGENT INFORMATION
If you are not a resident of North Carolina you must designate a resident agent. The resident agent's address must be the
same as the company address.
Resident Agent's Name:
Telephone Number:
Address:
City
State
Zip
County
FEES SUBMITTED
Fees for a new license are:
Fee to add a phase is:
Fee for a license transfer or
Enter total fee enclosed:
One phase:
$200.00
$75.00 for each phase.
replacement is $10.00
Two phases:
$275.00
Three phases: $350.00
INSURANCE INFORMATION
The license can not be issued without proof of insurance. Proof of insurance as required by G.S. 106-65.37 and 2 NCAC
34 .0902 must include a pollution and contamination endorsement clause. Insurance certificates are accepted from the
insurance company only.
APPLICANT AND RESIDENT AGENT CERTIFICATION
I hereby certify that the information given in this application is true and correct.
Signature of License Applicant::
Date:
Signature of Resident Agent: (required if applicable):
Date:
Form No. 18 (Revised Feb 2011)
INSTRUCTIONS FOR COMPLETING THE
LICENSE APPLICATION
APPLICANT INFORMATION
Complete all personal information for the applicant. Be sure to include the Job Title.
COMPANY INFORMATION
The company name and address of the company with which you are currently employed.
LICENSE INFORMATION
Check the appropriate box for New License, New Phase added to existing license, Transfer of
License from one employer to another, or Replacement of a lost license.
Check the box for the phase(s) to be included or added to the license.
EMPLOYEE INFORMATION
Indicate the number of employees who will perform structural pest control under your license. Do not
include yourself or clerical staff.
RESIDENT AGENT INFORMATION
This section applies only to licensees that reside outside of North Carolina. The resident agent
should be located at the home office location of the licensee in North Carolina.
FEES SUBMITTED
Fees required are listed on the front of the form. Be sure to indicate the amount paid and to include
your check or other form of payment with the application. Applications received without payment will
be returned.
INSURANCE INFORMATION
The license will not be issued without proof of insurance. It is always best to include the Certificate of
Insurance with the license application. For applications other than new licenses, be sure your
insurance information is current: not expired, issued in the company name indicated on the
application, etc.
APPLICANT AND RESIDENT AGENT CERTIFICATION
All applicable individuals must sign the application. Unsigned applications will be returned.

Download Form 18 Application for Structural Pest Control License - North Carolina

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