Form SFN17783 "Authorization to Receive Restricted Use Pesticides (Rup's)" - North Dakota

What Is Form SFN17783?

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

Form Details:

  • Released on February 1, 2013;
  • The latest edition provided by the North Dakota 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 fillable version of Form SFN17783 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Agriculture.

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Download Form SFN17783 "Authorization to Receive Restricted Use Pesticides (Rup's)" - North Dakota

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AUTHORIZATION TO RECEIVE RESTRICTED USE PESTICIDES (RUP's)
NORTH DAKOTA DEPARTMENT OF AGRICULTURE
ND Department of Agriculture
PESTICIDE AND FERTILIZER DIVISION
600 E Boulevard Ave Dept 602
SFN 17783 (2-2013)
Bismarck, ND 58505-0020
Telephone: 701-328-2231
This form must be completed in order for restricted use pesticides (RUP's) to be picked up by anyone other than the certified
person for the year as stated. The dealer is responsible to visually verify the certification number and expiration date.
Please list those persons authorised to receive RUP's on behalf of the certified applicator.
Authorized Person #1
Partner
Employee
Family Member
Authorized Person #2
Partner
Employee
Family Member
Authorized Person #3
Partner
Employee
Family Member
Authorized Person #4
Partner
Employee
Family Member
I have instructed the above-name individual on the proper safety, handling and transportation methods for the following
chemicals and that person is authorized to receive and sign for the receipt of the following chemicals on my account for the
20______ calendar year.
CHEMICAL NAME
CHEMICAL NAME
Name of Certified Applicator (please print)
Telephone Number
Certification Number
Expiration Date
Address
City
State
ZIP Code
Signature of Certified Applicator
Signature of Authorized Person #1
Date
Signature of Authorized Person #2
Date
Signature of Authorized Person #3
Date
Signature of Authorized Person #4
Date
DEALER: Keep this on file for 3 years.
Copy as needed.
AUTHORIZATION TO RECEIVE RESTRICTED USE PESTICIDES (RUP's)
NORTH DAKOTA DEPARTMENT OF AGRICULTURE
ND Department of Agriculture
PESTICIDE AND FERTILIZER DIVISION
600 E Boulevard Ave Dept 602
SFN 17783 (2-2013)
Bismarck, ND 58505-0020
Telephone: 701-328-2231
This form must be completed in order for restricted use pesticides (RUP's) to be picked up by anyone other than the certified
person for the year as stated. The dealer is responsible to visually verify the certification number and expiration date.
Please list those persons authorised to receive RUP's on behalf of the certified applicator.
Authorized Person #1
Partner
Employee
Family Member
Authorized Person #2
Partner
Employee
Family Member
Authorized Person #3
Partner
Employee
Family Member
Authorized Person #4
Partner
Employee
Family Member
I have instructed the above-name individual on the proper safety, handling and transportation methods for the following
chemicals and that person is authorized to receive and sign for the receipt of the following chemicals on my account for the
20______ calendar year.
CHEMICAL NAME
CHEMICAL NAME
Name of Certified Applicator (please print)
Telephone Number
Certification Number
Expiration Date
Address
City
State
ZIP Code
Signature of Certified Applicator
Signature of Authorized Person #1
Date
Signature of Authorized Person #2
Date
Signature of Authorized Person #3
Date
Signature of Authorized Person #4
Date
DEALER: Keep this on file for 3 years.
Copy as needed.