Form DEEP-FOR-APP-100 "Application for Commercial Forest Practitioner Certification" - Connecticut

What Is Form DEEP-FOR-APP-100?

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

Form Details:

  • Released on March 13, 2019;
  • The latest edition provided by the Connecticut Department of Energy and Environmental Protection;
  • 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 DEEP-FOR-APP-100 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Energy and Environmental Protection.

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CPPU USE ONLY
App #:________________________________
Doc #:________________________________
Check #:______________________________
Program: Forestry Certification
FPH
SFPH
F
#
EE
O
G
Application for Commercial Forest
Practitioner Certification
Please complete this form in accordance with the
instructions
(DEEP-FOR-INST-100) to ensure the proper
handling of this application. Print or type unless otherwise noted. The application and examination fee must be
submitted along with a completed application to the address specified at the end of this form.
Part I: Application Type and Fee Information
Select one type of certification: See General Information About Commercial Forest Practitioner Certification of the
application
instructions
for a description of the different types of certification.
Forester
Supervising Forest Products Harvester
Forest Products Harvester
Application Type
Application
Examination
Total Fee
Fee
Fee
Check the appropriate box identifying the application type.
New Application
$235.00
$65.00
$300.00
[#1895]
[#84]
New Application - Exempt from Examination Fee
$235.00
$235.00
[#1895]
(see instructions) must complete Attachment A
New Application - Retake of an examination (see instructions)
$65.00
$65.00
[#84]
Renewal Application
Existing Certification No.:
$235.00
$235.00
[#1895]
Expiration Date:
Check here, in addition to above boxes, if the applicant is a State or
Municipal employee for which certification is required for their
$0
$0
$0
employment. If this box is checked, the application and examination
fee are waived.
Check here, in addition to the above boxes, if the applicant is unable to read and is applying to take the oral
examination. If this box is checked, the person preparing this application must sign and complete Part IV.
Part II: Applicant Information
1.
Please provide the following information regarding the applicant.
Name:
Last
First
Middle
Mailing Address:
City/Town:
State:
Zip Code:
Home Phone:
Cell Phone:
*E-mail address:
Date of Birth:
*By providing this e-mail address you are agreeing to receive official correspondence from DEEP, at this electronic
address, concerning the subject application. Please remember to check your security settings to be sure you can receive
e-mails from “ct.gov” addresses. Also, please notify DEEP if your e-mail address changes.
Bureau of Natural Resources
DEEP-FOR-APP-100
1 of 4
Rev. 03/13/19
CPPU USE ONLY
App #:________________________________
Doc #:________________________________
Check #:______________________________
Program: Forestry Certification
FPH
SFPH
F
#
EE
O
G
Application for Commercial Forest
Practitioner Certification
Please complete this form in accordance with the
instructions
(DEEP-FOR-INST-100) to ensure the proper
handling of this application. Print or type unless otherwise noted. The application and examination fee must be
submitted along with a completed application to the address specified at the end of this form.
Part I: Application Type and Fee Information
Select one type of certification: See General Information About Commercial Forest Practitioner Certification of the
application
instructions
for a description of the different types of certification.
Forester
Supervising Forest Products Harvester
Forest Products Harvester
Application Type
Application
Examination
Total Fee
Fee
Fee
Check the appropriate box identifying the application type.
New Application
$235.00
$65.00
$300.00
[#1895]
[#84]
New Application - Exempt from Examination Fee
$235.00
$235.00
[#1895]
(see instructions) must complete Attachment A
New Application - Retake of an examination (see instructions)
$65.00
$65.00
[#84]
Renewal Application
Existing Certification No.:
$235.00
$235.00
[#1895]
Expiration Date:
Check here, in addition to above boxes, if the applicant is a State or
Municipal employee for which certification is required for their
$0
$0
$0
employment. If this box is checked, the application and examination
fee are waived.
Check here, in addition to the above boxes, if the applicant is unable to read and is applying to take the oral
examination. If this box is checked, the person preparing this application must sign and complete Part IV.
Part II: Applicant Information
1.
Please provide the following information regarding the applicant.
Name:
Last
First
Middle
Mailing Address:
City/Town:
State:
Zip Code:
Home Phone:
Cell Phone:
*E-mail address:
Date of Birth:
*By providing this e-mail address you are agreeing to receive official correspondence from DEEP, at this electronic
address, concerning the subject application. Please remember to check your security settings to be sure you can receive
e-mails from “ct.gov” addresses. Also, please notify DEEP if your e-mail address changes.
Bureau of Natural Resources
DEEP-FOR-APP-100
1 of 4
Rev. 03/13/19
Part II: Applicant Information (continued)
2.
Applicant Residence Address (if different than above):
City/Town:
State:
Zip Code:
3.
Emergency Contact Information:
Emergency Contact Name:
Relationship:
Phone Number:
4.
Please provide the following information regarding each employer for whom the applicant engages in Commercial
Forest Practices.
Zip
Name
Street Address
City/Town
State
Contact Person
Phone
Code
5.
For applicants who engage in Commercial Forest Practices under a business name, please provide the following
information for each business under which the applicant engages in Commercial Forest Practices.
Zip
Name
Street Address
City/Town
State
Contact Person
Phone
Code
6.
For applicants who do not engage in Commercial Forest Practices for an employer or under a business name please
provide the following information regarding each name or entity under which or for whom the applicant engages in
Commercial Forest Practices.
Name
Street Address
City/Town
State
Zip Code
Phone
Bureau of Natural Resources
DEEP-FOR-APP-100
2 of 4
Rev. 03/13/19
Part III. Additional Background Information
1. Applicants for Forester certification only (including renewal applications):
Name of Institution
Graduation Date
Degree Earned
2. For all Applicants:
A. For each state (including Connecticut) in which the applicant is currently or has previously been
registered, certified or licensed as a forest practitioner provide the following:
Name of
current registration,
if no longer registered, certified, or
Has a registration, certification or
State
certificate or license
licensed indicate why
license as a forest practitioner been
identifier (i.e.,
denied, revoked or suspended?
number):
Yes
No; If yes, give dates
and explain:
Yes
No; If yes, give dates
and explain:
Yes
No; If yes, give dates
and explain:
Yes
No; If yes, give dates
and explain:
B. Has the applicant ever been convicted of a felony associated with the conduct of a forest practice?
Yes
No
If yes, give dates and explain:
C. Within the past 3 years, has the applicant engaged in a forest practice for which a cease and desist
order, citation, or other administrative order has been issued from any federal, state, or local agency for
conduct associated with a forest practice ?
Yes
No If yes, give dates and explain:
Bureau of Natural Resources
DEEP-FOR-APP-100
3 of 4
Rev. 03/13/19
Part IV: Certification
The applicant and the preparer, if applicable, must sign this part.
“I have personally examined and am familiar with the information submitted in this document and all
attachments and certify that, based on reasonable investigation, the submitted information is true, accurate and
complete to the best of my knowledge and belief. I understand that any false statement made in this application
or its attachments may be grounds for denial, suspension, or revocation of a certification.”
Applicant Signature
Date
If an applicant is unable to read and has requested to take an examination orally, the person preparing this
application must sign and provide the information requested below.
“I declare under penalty of false statement that I have completed this application based upon the information
provided by the applicant and that to the best of my knowledge and belief the information in this application is
true, complete and correct.”
Signature of Preparer
Date
Preparer's Address:
City/Town:
State:
Zip Code:
Preparer's Phone:
ext.
Note:
Please submit this completed Application Form, including Attachment A if applicable, and Fee to:
CENTRAL PERMIT PROCESSING UNIT
DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION
79 ELM STREET
HARTFORD, CT 06106-5127
The applicant will be notified in writing of the exam date.
and required CEU’s must have been submitted. The applicant must
For Renewal applications, all
annual reports
submit all outstanding annual reports and CEUs with this completed application.
For questions, please contact the Forestry Division at 860-424-3630 or email at:
DEEP.Forestry@ct.gov
Bureau of Natural Resources
DEEP-FOR-APP-100
4 of 4
Rev. 03/13/19
Attachment A: Forest Products Harvester Examination Exemption
This form is to be completed and submitted with the application only if the applicant qualifies for the
Forest Products Harvester Examination Exemption.
Applicant's Name:
Last
First
Middle
Please reproduce and complete this Attachment for each employer for whom the applicant was employed by, or
for whom the applicant contracted to in the engagement of commercial forest practices and/or for each landowner
for whom the applicant engaged in commercial forest practices.
Part I. Employer or Landowner Information
Please check one of the following:
Employer
Landowner
1.
Provide Information concerning the Employer/Landowner:
Name:
Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.
Contact Person:
Title:
2.
The dates during which the applicant performed commercial forest practices:
From:
To:
3.
The estimated hours the applicant worked per week performing commercial forest practices:
4.
Briefly describe the commercial forest practice being performed (timber harvesting, tree planting, timber stand
improvement, amount of volume harvested, acres planted, etc.):
5.
Indicate the town(s) in which the commercial forest practice(s) were performed:
Bureau of Natural Resources
DEEP-FOR-APP-101
1 of 2
Rev. 06/20/17
Page of 6