Form P-17.1 "Application for Commercial Applicator Certification / Recertification" - Hawaii

What Is Form P-17.1?

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

Form Details:

  • Released on November 1, 2012;
  • The latest edition provided by the Hawaii 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 P-17.1 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Agriculture.

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Download Form P-17.1 "Application for Commercial Applicator Certification / Recertification" - Hawaii

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COM
FOR DEPT. OF AGRICULTURE USE ONLY
Pesticides Branch
Certification No.
Expiration Date
1428 S. King Street
Honolulu, HI 96814-2512
www.hawaii.gov/hdoa/pi/pest
Qualified by:
Exam
Recert. Credits___________
APPLICATION FOR
Examination Date: _______________________________
COMMERCIAL APPLICATOR
Card Issue / Pick-up Date: _________________________
CERTIFICATION / RECERTIFICATION
Receipt No.: ____________________________________
GIS Data Rec’d on:___________Updated on:___________
(Check appropriate box(es)):
New Certification
Certification Renewal
Updating Information
Categories applying for:__________________
Current Certification No. & Category _______________________
1. Name of Applicant: ________________________________________________ Title: ________________________________
2. Name of Business or Agency: _____________________________________________________________________________
3. Business Address: ______________________________________________________________________________________
STREET
CITY
_______________________________________
STATE
ZIP CODE
4. Mailing Address: _______________________________________________________________________________________
(if different from Business address)
STREET / P.O. BOX
CITY
Is this a Home Address? (circle one)
Yes
No
________________________________________
STATE
ZIP CODE
5. Business Phone: _____________________ Cell Phone: ______________________ Business Fax: ____________________
6. Emergency Contact Phone: ________________________ E-mail Address:_________________________________________
7. (For Golf Course Applicators Only): Is Geographic Information System (GIS) data available for your golf course?
(circle one)
Yes
No
(If no, an Education/Certification staff member will contact you to schedule a time to collect the data. GIS data is required
prior to issuance of certification cards.)
************************************************************************************
STATEMENT
I declare under penalty of perjury, under the laws of the State of Hawaii, that the above information is true and correct.
_________________________________________________________ ___________________________
SIGNATURE
DATE
For examination scheduling, contact the Education Specialist covering your district.
Honolulu Office
Hilo Office
Maui Office (covered by Honolulu Office) Kauai Office (covered by Honolulu Office)
Ph. (808) 973-9409
Ph. (808) 974-4143
Ph. Maui State Toll Free Access:
Ph. Kauai State Toll Free Access:
Ph. (808) 973-9424
Cell (808) 333-2844
984-2400 ext. 39404 or 39424 (Honolulu)
274-3141 ext. 39409 or 39424 (Honolulu)
Fax (808) 973-9418
Fax (808) 974-4148
Fax (808) 873-3586 (Maui)
Fax (808) 274-3067 (Kauai Office)
Form P-17.1 Rev. 11/12
COM
FOR DEPT. OF AGRICULTURE USE ONLY
Pesticides Branch
Certification No.
Expiration Date
1428 S. King Street
Honolulu, HI 96814-2512
www.hawaii.gov/hdoa/pi/pest
Qualified by:
Exam
Recert. Credits___________
APPLICATION FOR
Examination Date: _______________________________
COMMERCIAL APPLICATOR
Card Issue / Pick-up Date: _________________________
CERTIFICATION / RECERTIFICATION
Receipt No.: ____________________________________
GIS Data Rec’d on:___________Updated on:___________
(Check appropriate box(es)):
New Certification
Certification Renewal
Updating Information
Categories applying for:__________________
Current Certification No. & Category _______________________
1. Name of Applicant: ________________________________________________ Title: ________________________________
2. Name of Business or Agency: _____________________________________________________________________________
3. Business Address: ______________________________________________________________________________________
STREET
CITY
_______________________________________
STATE
ZIP CODE
4. Mailing Address: _______________________________________________________________________________________
(if different from Business address)
STREET / P.O. BOX
CITY
Is this a Home Address? (circle one)
Yes
No
________________________________________
STATE
ZIP CODE
5. Business Phone: _____________________ Cell Phone: ______________________ Business Fax: ____________________
6. Emergency Contact Phone: ________________________ E-mail Address:_________________________________________
7. (For Golf Course Applicators Only): Is Geographic Information System (GIS) data available for your golf course?
(circle one)
Yes
No
(If no, an Education/Certification staff member will contact you to schedule a time to collect the data. GIS data is required
prior to issuance of certification cards.)
************************************************************************************
STATEMENT
I declare under penalty of perjury, under the laws of the State of Hawaii, that the above information is true and correct.
_________________________________________________________ ___________________________
SIGNATURE
DATE
For examination scheduling, contact the Education Specialist covering your district.
Honolulu Office
Hilo Office
Maui Office (covered by Honolulu Office) Kauai Office (covered by Honolulu Office)
Ph. (808) 973-9409
Ph. (808) 974-4143
Ph. Maui State Toll Free Access:
Ph. Kauai State Toll Free Access:
Ph. (808) 973-9424
Cell (808) 333-2844
984-2400 ext. 39404 or 39424 (Honolulu)
274-3141 ext. 39409 or 39424 (Honolulu)
Fax (808) 973-9418
Fax (808) 974-4148
Fax (808) 873-3586 (Maui)
Fax (808) 274-3067 (Kauai Office)
Form P-17.1 Rev. 11/12
CATEGORIES OF COMMERCIAL APPLICATORS
(Refer to Administrative Rules, Chapter 66, Section 4-66-56 for specific requirements on each category /subcategory)
Category
1.
AGRICULTURAL PEST CONTROL
(a)
Plant Pest Control. Includes persons using or supervising the use of restricted use pesticides in production of agricultural food and
feed crops, including, but not limited to grains, seeds, soybeans, forage, vegetables, fruits, trees and nuts, as
well as non-crop agricultural lands.
(b)
Animal Pest Control. Includes persons using or supervising the use of restricted use pesticides to control pests on animals
including, but not limited to beef and dairy cattle, swine, sheep, horses, goats, and poultry, and to premises on
or in which animals are confined; and doctors of veterinary medicine engaged in the business of application for
hire, publicly holding themselves out as pesticide applicators or engaged in large scale use of pesticides.
2.
FOREST PEST CONTROL
Includes persons using or supervising the use of restricted use pesticides in forests, forest nurseries, and forest seed producing areas.
3.
ORNAMENTAL AND TURF PEST CONTROL
Includes persons using or supervising the use of restricted use pesticides to control of pests of ornamental trees, shrubs, flowers and turf.
4.
AERIAL PEST CONTROL
Includes individuals using or supervising the use of restricted use pesticides applied by aircraft.
5.
AQUATIC PEST CONTROL
Includes persons using or supervising the use of restricted use pesticides purposefully applied to standing or running water, excluding
applicators engaged in public health related activities included in category 8 below.
6.
RIGHT-OF-WAY PEST CONTROL
Includes persons using or supervising the use of restricted use pesticides in the maintenance of public roads, electric power lines, pipelines,
railway rights-of-way or other similar areas, excluding aquatic rights-of-way.
7.
INDUSTRIAL, INSTITUTIONAL STRUCTURAL AND PUBLIC HEALTH RELATED PEST CONTROL
Includes persons using or supervising the use of restricted use pesticides to control pests in, on, or around food handling establishments,
human dwelling, institutions, such as schools and hospitals, industrial sites, including warehouses and grain elevators, and any other structures
and adjacent areas, public or private, and for the protection of stored, processed or manufactured products. Subcategories:
(a)
Fumigation Pest Control (for licensed pest control operators only)
(b)
Termite Pest Control (for licensed pest control operators only)
(c)
General Pest Control (for licensed pest control operators only)
(d)
Institutional Pest Control
(e)
Vault Fumigation Pest Control
(f)
Specialty Categories (product specific and/or site specific uses)
8.
PUBLIC HEALTH PEST CONTROL
Includes federal, state, or other governmental employees using or supervising the use of restricted use pesticides in public health programs for
the management and control of pests having medical and public health importance.
9.
REGULATORY PEST CONTROL
Includes federal, state or other governmental employees using or supervising the use of restricted use pesticides in public health programs for
the management and control of regulated pests prescribed under Chapter 150A, HRS, and the Federal Plant Pest Act.
10.
DEMONSTRATION, RESEARCH AND INSTRUCTIONAL PEST CONTROL
Includes: 1) persons who demonstrates to the public the proper use and techniques of application of restricted use pesticides or supervise
such demonstration (includes such persons as extension specialists and county agents, commercial representatives demonstrating pesticide
products, and those individuals demonstrating methods used in public programs); and 2) persons conducting field research with pesticides, and
in doing so, use or supervise the use of restricted use pesticides (includes federal, state, commercial and other persons conducting field
research on or utilizing restricted use pesticides).
11.
Chemigation Pest Control
Includes persons using or supervising the use of restricted use pesticides applied through an irrigation system. Requires concurrent
certification in category 1a, 2, 3, or 10.
[Form P-17.1(a) Rev.11/12]
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