"Aerial Applicator Consultant Registration for Iowa Commercial Aerial Pesticide Applicator" - Iowa

Aerial Applicator Consultant Registration for Iowa Commercial Aerial Pesticide Applicator is a legal document that was released by the Iowa Department of Agriculture and Land Stewardship - a government authority operating within Iowa.

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Aerial Applicator Consultant Registration
2019
For Iowa Commercial Aerial Pesticide Applicator
Iowa Department of Agriculture
IDALS USE ONLY
Consultant ID No.
and Land Stewardship (IDALS)
This form is to be completed by the Aerial
Pesticide Bureau – Wallace Building
502 East 9th Street - Des Moines, IA 50319-0051
Applicator Consultant and submitted by the Aerial
Applicator as part of license application package.
P
515-281-5601
F
515-242-6497
HONE
AX
https://iowaagriculture.gov/pesticide-bureau
WEBSITE
Please Type or Print
Consultant Name
(Last Name, First Name, Middle Initial)
Iowa Commercial Pesticide
____ ____ ____ ____ ____
/___________
Expiration Date: 12/31
Applicator Certification No.:
(
)
:
Home Phone
Consultant’s HOME Address:
Consultant’s HOME City, State & Zip Code
Employed by,
Business Name:
Business Physical Address:
(no PO Box addresses allowed)
Business City, State, Zip
(
)
(
)
Business Fax:
Business Phone
:
(
)
Cell Phone
Email Address
12/31/______
Iowa Commercial Pesticide Applicator License No.
Expiration
__ __ __ __ __--__ __ __
(Company Lic. No.)
Date
(if none, mark “N/A”)
__
6/30/_______
Iowa Pesticide Dealer License No.
Expiration
__ __ __ __ __--__ __ __
(Company Lic. No.)
date
__
(if none, mark “N/A”)
Check each box that represents a true statement:
I am an owner or employee of a corporation, association, partnership, company or firm, which maintains
a physical place of business located in Iowa.
I am certified in category 11 – Aerial Application.
I do not operate agricultural aircraft.
I own and operate, or am employed by an Iowa-based company that owns and operates, agricultural
aircraft registered with the Iowa Department of Transportation. (Contracting of services does not
constitute employment for purposes of this rule.)
I will be coordinating aerial application work for the following:
(one applicator/license per form)
Pilot’s IA Applicator Certification No.
Aerial Applicator Name (Pilot's Name)
-OR- check box to indicate advance
registration with pilot info to be provided at
Pilot’s business name and address, including city, state and zip code
a later date
Pilot’s IA Company License No.
Check here if additional pilots are listed on the reverse side of this document
I verify that the above information is true and that I have agreed to act as the aerial applicator consultant for the above-named
aerial applicator applying pesticides in Iowa for the licensing year noted on this form, in accordance with 21 IAC 45.22(17).
___________________________________________________________________________________________________________
Consultant Signature
Date Signed
Previous versions of this form are obsolete.
Aerial Applicator Consultant Registration
2019
For Iowa Commercial Aerial Pesticide Applicator
Iowa Department of Agriculture
IDALS USE ONLY
Consultant ID No.
and Land Stewardship (IDALS)
This form is to be completed by the Aerial
Pesticide Bureau – Wallace Building
502 East 9th Street - Des Moines, IA 50319-0051
Applicator Consultant and submitted by the Aerial
Applicator as part of license application package.
P
515-281-5601
F
515-242-6497
HONE
AX
https://iowaagriculture.gov/pesticide-bureau
WEBSITE
Please Type or Print
Consultant Name
(Last Name, First Name, Middle Initial)
Iowa Commercial Pesticide
____ ____ ____ ____ ____
/___________
Expiration Date: 12/31
Applicator Certification No.:
(
)
:
Home Phone
Consultant’s HOME Address:
Consultant’s HOME City, State & Zip Code
Employed by,
Business Name:
Business Physical Address:
(no PO Box addresses allowed)
Business City, State, Zip
(
)
(
)
Business Fax:
Business Phone
:
(
)
Cell Phone
Email Address
12/31/______
Iowa Commercial Pesticide Applicator License No.
Expiration
__ __ __ __ __--__ __ __
(Company Lic. No.)
Date
(if none, mark “N/A”)
__
6/30/_______
Iowa Pesticide Dealer License No.
Expiration
__ __ __ __ __--__ __ __
(Company Lic. No.)
date
__
(if none, mark “N/A”)
Check each box that represents a true statement:
I am an owner or employee of a corporation, association, partnership, company or firm, which maintains
a physical place of business located in Iowa.
I am certified in category 11 – Aerial Application.
I do not operate agricultural aircraft.
I own and operate, or am employed by an Iowa-based company that owns and operates, agricultural
aircraft registered with the Iowa Department of Transportation. (Contracting of services does not
constitute employment for purposes of this rule.)
I will be coordinating aerial application work for the following:
(one applicator/license per form)
Pilot’s IA Applicator Certification No.
Aerial Applicator Name (Pilot's Name)
-OR- check box to indicate advance
registration with pilot info to be provided at
Pilot’s business name and address, including city, state and zip code
a later date
Pilot’s IA Company License No.
Check here if additional pilots are listed on the reverse side of this document
I verify that the above information is true and that I have agreed to act as the aerial applicator consultant for the above-named
aerial applicator applying pesticides in Iowa for the licensing year noted on this form, in accordance with 21 IAC 45.22(17).
___________________________________________________________________________________________________________
Consultant Signature
Date Signed
Previous versions of this form are obsolete.
Aerial Applicator Consultant Registration
(continued from page 1)
2019
--Page 2--
Consultant Name:_______________________________ Consultant Appl. Certification No.___________
All the aerial applicators that you have listed as working with you (as an
aerial consultant) will remain in our records UNTIL you notify IDALS
NOTICE:
in writing that you wish to remove any of them from your list of pilots.
Fax (515) 242-6497. Email:
Tammy.Green@IowaAgriculture.gov
I will also be coordinating aerial application work for the following Aerial Applicators:
Pilot’s IA Applicator Certification No.
Name))R-
Aerial Applicator Name (Pilot's
check box to indicate advance registration/
info to be provided at a later date
Pilot’s business name and address, including city ,state and zip code
Pilot’s IA Company License No.
Pilot’s IA Applicator Certification No.
Aerial Applicator Name (Pilot's Name)
-
OR- check box to indicate advance
registration/ info to be provided at a later
Pilot’s business name and address, including city, state and zip code
date
Pilot’s IA Company License No.
Aerial Applicator Name (Pilot's Name)
Pilot’s IA Applicator Certification No.
OR- check box to indicate advance
registration/ info to be provided at a later
Pilot’s business name and address, including city, state and zip code
date
Pilot’s IA Company License No.
Pilot’s IA Applicator Certification No.
Aerial Applicator Name (Pilot's Name)
OR- check box to indicate advance
registration/ info to be provided at a later
Pilot’s business name and address, including city, state and zip code
date
Pilot’s IA Company License No.
Aerial Applicator Name (Pilot's Name)
Pilot’s IA Applicator Certification No.
-
OR- check box to indicate advance
registration/ info to be provided at a later
Pilot’s business name and address, including city, state and zip code
date
Pilot’s IA Company License No.
I verify that the above information is true and have agreed to act as the aerial applicator consultant for the above-
named aerial applicator(s) applying pesticides in Iowa for the licensing year noted on this form, in accordance
with 21 IAC 45.22(17).
___________________________________________________________________________________________________________
Consultant Signature
Date Signed
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