Form DP-25 "Application for a Private Applicator's Restricted Use Pesticide License" - Arkansas

What Is Form DP-25?

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

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the Arkansas Agriculture Department;
  • 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 DP-25 by clicking the link below or browse more documents and templates provided by the Arkansas Agriculture Department.

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Download Form DP-25 "Application for a Private Applicator's Restricted Use Pesticide License" - Arkansas

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Form DP-25 (Rev. 04/2020)
APPLICATION FOR A PRIVATE APPLICATOR’S
RESTRICTED USE PESTICIDE LICENSE
INSTRUCTIONS: Complete and submit with required fees to the Arkansas Department of Agriculture, Plant
Industries Division, Pesticide Section, P.O. Box 1069, Little Rock, Arkansas 72203. Upon approval, your license will
be issued for the year indicated. Note: To qualify for this license an individual must be a producer of an agricultural
commodity. Incomplete applications will delay processing. Print or Type ONLY!
MAKE CHECK PAYABLE TO: ARKANSAS STATE PLANT BOARD
PERSON APPLYING:
*
Note: Fields indicated with
are required and must be filled out or the application form is considered incomplete!
*
*
Name:
Last
First
Middle_
_
(Please Print)
*
Date of Birth
_________________________
*
*
Mailing Address
City __________________________________
*
*
*
State
Zip Code
Phone Number
Cell Phone (Opt) _______________
*
Email Address _______________________________________________________
*
*
Residential County
Farm Location County _______________________________
*
Indicate Type of Operation (farmer, rancher, nurseryman, etc.) ______________________________________________
*
Indicate Agricultural Commodity Produced (rice, hay, cattle, timber, etc.) _____________________________________
If above is a new address, list old address here ___________________________________________________________
To be eligible for a one year license, one must have been certified or re-certified within the past forty-eight (48) months.
To be eligible for a five year license, one must have been certified or re-certified within the past twelve (12) months,
without previously having a license on that certification.
*Certification received by watching a video at the County Extension Office makes one only eligible for one 1-year license.
□ ONE YEAR LICENSE $10
□ FIVE YEAR LICENSE $45
*
APPLICATION FEE ENCLOSED:
OR
Applicant stipulates that the restricted use pesticide purchased or secured will be used on his or her own, rented or leased premises in
accordance with label directions and agrees to comply with the requirements of the Pesticide Use and Application Act as amended, and
Pesticide Control Act as amended, and Regulations promulgated pursuant there to.
Applicant’s
*
*
Signature:
Date: _________________________________
(Person Applying Only)
*******************************************************************************************
DO NOT WRITE IN THIS SPACE
______________
License Number
Date of Issuance
Form DP-25 (Rev. 04/2020)
APPLICATION FOR A PRIVATE APPLICATOR’S
RESTRICTED USE PESTICIDE LICENSE
INSTRUCTIONS: Complete and submit with required fees to the Arkansas Department of Agriculture, Plant
Industries Division, Pesticide Section, P.O. Box 1069, Little Rock, Arkansas 72203. Upon approval, your license will
be issued for the year indicated. Note: To qualify for this license an individual must be a producer of an agricultural
commodity. Incomplete applications will delay processing. Print or Type ONLY!
MAKE CHECK PAYABLE TO: ARKANSAS STATE PLANT BOARD
PERSON APPLYING:
*
Note: Fields indicated with
are required and must be filled out or the application form is considered incomplete!
*
*
Name:
Last
First
Middle_
_
(Please Print)
*
Date of Birth
_________________________
*
*
Mailing Address
City __________________________________
*
*
*
State
Zip Code
Phone Number
Cell Phone (Opt) _______________
*
Email Address _______________________________________________________
*
*
Residential County
Farm Location County _______________________________
*
Indicate Type of Operation (farmer, rancher, nurseryman, etc.) ______________________________________________
*
Indicate Agricultural Commodity Produced (rice, hay, cattle, timber, etc.) _____________________________________
If above is a new address, list old address here ___________________________________________________________
To be eligible for a one year license, one must have been certified or re-certified within the past forty-eight (48) months.
To be eligible for a five year license, one must have been certified or re-certified within the past twelve (12) months,
without previously having a license on that certification.
*Certification received by watching a video at the County Extension Office makes one only eligible for one 1-year license.
□ ONE YEAR LICENSE $10
□ FIVE YEAR LICENSE $45
*
APPLICATION FEE ENCLOSED:
OR
Applicant stipulates that the restricted use pesticide purchased or secured will be used on his or her own, rented or leased premises in
accordance with label directions and agrees to comply with the requirements of the Pesticide Use and Application Act as amended, and
Pesticide Control Act as amended, and Regulations promulgated pursuant there to.
Applicant’s
*
*
Signature:
Date: _________________________________
(Person Applying Only)
*******************************************************************************************
DO NOT WRITE IN THIS SPACE
______________
License Number
Date of Issuance