Form PA-400N "Application for Pesticide Applicator License" - Texas

What Is Form PA-400N?

This is a legal form that was released by the Texas Department of Agriculture - a government authority operating within Texas. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the Texas 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 PA-400N by clicking the link below or browse more documents and templates provided by the Texas Department of Agriculture.

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Download Form PA-400N "Application for Pesticide Applicator License" - Texas

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P.O. Box 12076 Austin, Texas 78711
(877) 542-2474
(512) 463-7476
Hearing impaired: (800) 735-2988 voice
(800) 735-2989 (TTY)
www.TexasAgriculture.gov
Texas Department of Agriculture
Application for
PA-400N
Pesticide Applicator License
1
TDA USE ONLY
TYPE OF LICENSE (PLEASE CHECK ONE)
PA-400
Noncommercial ($140 Fee)
Client No.
Account No.
Noncommercial Political Subdivision ($75 Fee)
Date (mm/dd/yy)
Initials
/
/
1
CLIENT INFORMATION
Driver License No. __________________ (required)
TX
State Issued ID No. __________________ ( if DL is not available)
Other ______
First Name (Legal Name)
M. I.
Last Name
Mailing Address
City
State
Zip
Phone
(
)
-
Ext.
1
PERSON TO CONTACT FOR LICENSE-RELATED MATTERS
SAME AS CLIENT NAME
First Name
M. I.
Last Name
Primary Phone
Secondary Phone (optional)
(
)
-
Ext.
(
)
-
Ext.
Fax (optional)
(
)
-
Ext.
E-mail Address:
***Important Note*** I understand that my email address is required by the Texas Department of Agriculture to keep me
informed of critical information, including licensing and regulatory updates; renewal invoices; and other important
communications. Failure to provide an email address may result in my not receiving time-sensitive information that could
affect my compliance with state regulations and result in monetary penalties.
2
MAILING ADDRESS
SAME AS CLIENT ADDRESS
Address
City
State
Zip
This document becomes public record and is subject to disclosure. With few exceptions, you have the right to request
and be informed about the information that the State of Texas collects about you. You are entitled to receive and
review the information upon request. You also have the right to ask the state agency to correct any information that is
determined to be incorrect. (Reference: Government Code, Sections 552.021, 552.023, and 559.004.)
Licensing Department
Revised 1/1/16
Administrative Services Division
Nonoccupational
P.O. Box 12076 Austin, Texas 78711
(877) 542-2474
(512) 463-7476
Hearing impaired: (800) 735-2988 voice
(800) 735-2989 (TTY)
www.TexasAgriculture.gov
Texas Department of Agriculture
Application for
PA-400N
Pesticide Applicator License
1
TDA USE ONLY
TYPE OF LICENSE (PLEASE CHECK ONE)
PA-400
Noncommercial ($140 Fee)
Client No.
Account No.
Noncommercial Political Subdivision ($75 Fee)
Date (mm/dd/yy)
Initials
/
/
1
CLIENT INFORMATION
Driver License No. __________________ (required)
TX
State Issued ID No. __________________ ( if DL is not available)
Other ______
First Name (Legal Name)
M. I.
Last Name
Mailing Address
City
State
Zip
Phone
(
)
-
Ext.
1
PERSON TO CONTACT FOR LICENSE-RELATED MATTERS
SAME AS CLIENT NAME
First Name
M. I.
Last Name
Primary Phone
Secondary Phone (optional)
(
)
-
Ext.
(
)
-
Ext.
Fax (optional)
(
)
-
Ext.
E-mail Address:
***Important Note*** I understand that my email address is required by the Texas Department of Agriculture to keep me
informed of critical information, including licensing and regulatory updates; renewal invoices; and other important
communications. Failure to provide an email address may result in my not receiving time-sensitive information that could
affect my compliance with state regulations and result in monetary penalties.
2
MAILING ADDRESS
SAME AS CLIENT ADDRESS
Address
City
State
Zip
This document becomes public record and is subject to disclosure. With few exceptions, you have the right to request
and be informed about the information that the State of Texas collects about you. You are entitled to receive and
review the information upon request. You also have the right to ask the state agency to correct any information that is
determined to be incorrect. (Reference: Government Code, Sections 552.021, 552.023, and 559.004.)
Licensing Department
Revised 1/1/16
Administrative Services Division
Nonoccupational
PA-400 Application for Pesticide Applicator License
Page 2 of 2
Applicant Name _________________________
1
FACILITY (LOCATION OF LICENSEE, LICENSED ACTIVITIES OR EQUIPMENT)
Facility Name (Person or Business Name)
2
PHYSICAL ADDRESS OF FACILITY
Address (No P.O. Box)
City
State
Zip
County
Directions to Physical Location
1
EMPLOYER INFORMATION (NONCOMMERCIAL & NC POLITICAL)
SAME AS FACILITY
Full Legal Name of Business (Headquarters)
Phone
(
)
-
Ext.
Physical Address
City
State
Zip
1
SIGNATURE
The applicant, by signature below, (1) certifies that all information provided in or in connection with this
application is true and correct; (2) acknowledges that any misrepresentation or false statement made by the
applicant, or an authorized agent of the applicant, in or in connection with this application, whether intentional or
not, will constitute grounds for denial, revocation, or non-renewal of any license issued pursuant to this application
and/or assessment of monetary administrative penalties; and (3) if applying as an individual, further acknowledges
that this application may be denied and that any license issued pursuant to this application may be suspended,
revoked, or denied renewal due to delinquency in payment of a guaranteed student loan and that any license issued
pursuant to this application may be suspended or denied renewal for failure to pay child support. If signed by an
agent or employee of the applicant, the person signing certifies that he or she is authorized to make the preceding
certifications on behalf of the applicant.
Title
Applicant Name (print)
Date (mm/dd/yy)
Applicant Signature
/
/
Mail to:
Texas Department of Agriculture
P.O. Box 12076
Austin, TX 78711-2076
Licensing Department
Revised 1/1/16
Administrative Services Division
Nonoccupational
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