Form 009-403-AA "Application for Iowa Commercial Aerial Pesticide Applicator License" - Iowa

What Is Form 009-403-AA?

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

Form Details:

  • Released on December 15, 2011;
  • The latest edition provided by the Iowa Department of Agriculture and Land Stewardship;
  • 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 009-403-AA by clicking the link below or browse more documents and templates provided by the Iowa Department of Agriculture and Land Stewardship.

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Download Form 009-403-AA "Application for Iowa Commercial Aerial Pesticide Applicator License" - Iowa

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Application for Iowa Commercial AERIAL Pesticide Applicator License
Iowa Department of Agriculture and Land
Office Use Only
Licensing Year
Stewardship (IDALS)
Insurance
License
Mailed
Pesticide Bureau – Wallace Building
502 East Ninth Street - Des Moines, IA 50319-0051
This form is for aerial applicators only.
If you are not an
aerial applicator, use form #009-0403, Application for Iowa
P
515-281-5601
F
515-242-6497
HONE
AX
Commercial Pesticide Applicator License. Check our website for
http://www.iowaagriculture.gov/pesticides.asp
WEBSITE
.
testing opportunities as well as for laws, forms, etc
Please Type or Print Legibly. Incomplete applications will be returned.
County of Site
Business Name
Address:
Business Owner
Business Site Address - - Street, City, Zip+4
Name of Person
Responsible for
Business Operation
(
)
Business Phone
Mailing Address, if different than above –
(
)
Business Fax
Street, City, Zip+4
Same as site address
Business E-mail
FAA Part 137 Certificate Number:
FAA Part 137 Chief Supervisor Name:
Chief Supervisor Primary Phone Number with area code
Chief Supervisor Alternate phone number with area code
Check One
Corporation
Partnership
Sole Proprietorship
Individual
Listing of Iowa Aerial Consultant(s) for the current licensing year
Name of Aerial
Certification Number of Aerial
Consultant #1
Consultant #1
:
(if available or pending)
Name of Aerial
Certification Number of Aerial
Consultant #2
Consultant #2
:
(if available or pending)
Name of Aerial
Certification Number of Aerial
Consultant #3
Consultant #3:
(if available or pending)
The following documentation is being provided in support of this license application:
$25 annual company license fee payable to “IDALS”
Checklist for Aerial Applicator Secondary Containment
Pilots hold Iowa Category 11 certification
Requirements (if using other containment facilities than
Current proof of insurance on file for all aircraft to be
previous year)
operated in Iowa
Aerial Applicator Consultant Registration
Iowa Agent Designation Form on file (for out-of-state
Pesticide Handlers Certified
applicators)
Proof of FAA Part 137 certification
Certification For Compliance With Secondary Containment
Proof of IDOT registration for aircraft
This is my application for an Iowa commercial aerial pesticide applicators license, and I declare all information on this form plus supporting
documentation I have included is true and correct. I understand that certification, containment, aerial applicator consultant, agent designation and
financial requirements must also be met before this license is valid.
__________________________________________________________________________________________
License Applicant’s Signature
License Applicant’s name
Date
PRINTED
T
HE FRONT AND BACK OF THIS FORM MUST BE COMPLETE AND LEGIBLE
.
AND ALL REQUIRED DOCUMENTS SUBMITTED WITH IT OR YOUR APPLICATION MAY BE RETURNED
Form 009-403-AA
Val 64
$25
12/15/11 H:\groups\pest\License\Applicat\Aerial Applicators\AerialApplicatorLicenseApp Rev2012.doc
Application for Iowa Commercial AERIAL Pesticide Applicator License
Iowa Department of Agriculture and Land
Office Use Only
Licensing Year
Stewardship (IDALS)
Insurance
License
Mailed
Pesticide Bureau – Wallace Building
502 East Ninth Street - Des Moines, IA 50319-0051
This form is for aerial applicators only.
If you are not an
aerial applicator, use form #009-0403, Application for Iowa
P
515-281-5601
F
515-242-6497
HONE
AX
Commercial Pesticide Applicator License. Check our website for
http://www.iowaagriculture.gov/pesticides.asp
WEBSITE
.
testing opportunities as well as for laws, forms, etc
Please Type or Print Legibly. Incomplete applications will be returned.
County of Site
Business Name
Address:
Business Owner
Business Site Address - - Street, City, Zip+4
Name of Person
Responsible for
Business Operation
(
)
Business Phone
Mailing Address, if different than above –
(
)
Business Fax
Street, City, Zip+4
Same as site address
Business E-mail
FAA Part 137 Certificate Number:
FAA Part 137 Chief Supervisor Name:
Chief Supervisor Primary Phone Number with area code
Chief Supervisor Alternate phone number with area code
Check One
Corporation
Partnership
Sole Proprietorship
Individual
Listing of Iowa Aerial Consultant(s) for the current licensing year
Name of Aerial
Certification Number of Aerial
Consultant #1
Consultant #1
:
(if available or pending)
Name of Aerial
Certification Number of Aerial
Consultant #2
Consultant #2
:
(if available or pending)
Name of Aerial
Certification Number of Aerial
Consultant #3
Consultant #3:
(if available or pending)
The following documentation is being provided in support of this license application:
$25 annual company license fee payable to “IDALS”
Checklist for Aerial Applicator Secondary Containment
Pilots hold Iowa Category 11 certification
Requirements (if using other containment facilities than
Current proof of insurance on file for all aircraft to be
previous year)
operated in Iowa
Aerial Applicator Consultant Registration
Iowa Agent Designation Form on file (for out-of-state
Pesticide Handlers Certified
applicators)
Proof of FAA Part 137 certification
Certification For Compliance With Secondary Containment
Proof of IDOT registration for aircraft
This is my application for an Iowa commercial aerial pesticide applicators license, and I declare all information on this form plus supporting
documentation I have included is true and correct. I understand that certification, containment, aerial applicator consultant, agent designation and
financial requirements must also be met before this license is valid.
__________________________________________________________________________________________
License Applicant’s Signature
License Applicant’s name
Date
PRINTED
T
HE FRONT AND BACK OF THIS FORM MUST BE COMPLETE AND LEGIBLE
.
AND ALL REQUIRED DOCUMENTS SUBMITTED WITH IT OR YOUR APPLICATION MAY BE RETURNED
Form 009-403-AA
Val 64
$25
12/15/11 H:\groups\pest\License\Applicat\Aerial Applicators\AerialApplicatorLicenseApp Rev2012.doc
T
HE FRONT AND BACK OF THIS FORM MUST BE COMPLETE AND LEGIBLE AND ALL REQUIRED DOCUMENTS
.
SUBMITTED WITH IT OR YOUR APPLICATION MAY BE RETURNED
List all pesticide applicators and handlers you employ with their certification and social security numbers. List new
employees you intend to certify and write their initial date of employment in the box labeled Certification Number.
If you have more employees than space allows, add a separate page and use the same format.
Any change in applicator, handler or consultant status
must be reported immediately to the pesticide bureau.
Updates must be in writing. Fax, e-mail, or mail accepted.
See 45.22(9) IAC
Certification Number
Individual’s Full Legal Name
Social Security Number
DO YOU NEED A PESTICIDE DEALER LICENSE ALSO?
Yes, if you distribute or otherwise bill for any
restricted use pesticide (
) or more than $10,000 of pesticides labeled for agricultural and/or lawn and garden.
RUP
Each business location is required to be licensed.
See 206.8 Iowa Code and 21—45.26 IAC
------------------------------------------------------------------------------------------------------------------------------------------------------------------
YOU MUST KEEP RECORDS OF APPLICATION.
See 21--45.26(206) IAC.
B
.
!
E AWARE OF THE FOLLOWING
IT MAY APPLY TO YOU
ATRAZINE MANAGEMENT .
CONTAINMENT RULES.
See Chapter 45.51 IAC .
See Chapter 44 IAC.
BEE RULE.
AERIAL APPLICATOR CONSULTANT.
See Chapter 45.31 IAC.
See 45.22(17) IAC.
IOWA SENSITIVE CROPS REGISTRY.
http://www.iowaagriculture.gov/Horticulture_and_FarmersMarkets/sensitiveCropDirectory.asp
Chapter 206 Iowa Code
Title 21 Chapters 44 and 45 Iowa Administrative Code (IAC)
Http://www.iowaagriculture.gov/pesticides.asp
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