"Request for Replacement Private Applicator Permit" - Alabama

Request for Replacement Private Applicator Permit is a legal document that was released by the Alabama Department of Agriculture and Industries - a government authority operating within Alabama.

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A
S
tate of
LABAMA
D
A
I
EPARTMENT OF
GRICULTURE AND
NDUSTRIES
Pesticide Management Division
1445 Federal Drive ● Montgomery, Alabama 36107-1123
(334) 240-7243 ● 1-800-642-7761, Ext. 7243
Rick Pate
Commissioner
REQUEST FOR REPLACEMENT
PRIVATE APPLICATOR PERMIT
I hereby apply for a replacement Private Applicator permit to purchase and use restricted use pesticides pursuant
to Chapter 27, Title 2, Code of Alabama (1975) and Chapter 80-1-13, Alabama Administrative Code. I understand and
will comply with the provisions of the above statutes and rules, as well as product label instructions. Further, I
understand that any violation of the statutes, rules, or label instructions constitutes grounds for suspension or
revocation of permit, and other penalties.
PLEASE PRINT
____________________________________________________________
xxx-xx-
Last name
First Name
Middle Name
Last 4 of SSN
____________________________________________________________
________________________
Home Address
County
Date of Birth
____________________________________________________________
(_____)_________________
City
State
Zip Code
Telephone Number
____________________________________________________________
________________________
Email Address
Permit Number
➢ Mailing address:
{ } Same as above OR as follows:
__________________________________________________________________________________________
Street Address
City
State
Zip
➢ Along with this application, you must include a $5.00 check or money order payable to the Alabama
Department of Agriculture and Industries.
➢ MAIL TO:
Department of Agriculture and Industries
Pesticide Management ~ Private Applicator
1445 Federal Drive
Montgomery, AL 36107-1123
I understand that this permit is valid only for purchasing, using, or supervising the use of restricted use
pesticide(s) on property owned/leased/controlled by me or by a full-time employee for the purpose of producing
agricultural commodities. My signature is to attest that I have read and understand the rules and regulations of a private
applicator.
Signature of Applicant__________________________________________________
Date_____________________
-------------------------------------------FOR ADAI OFFICE USE ONLY----------------------------------------------
Permit Number
Reissue Date______________________________________________
CK/MO # _____________________________ Amt Paid $________
www.agi.alabama.gov
“We provide employment & services without discrimination.”
A
S
tate of
LABAMA
D
A
I
EPARTMENT OF
GRICULTURE AND
NDUSTRIES
Pesticide Management Division
1445 Federal Drive ● Montgomery, Alabama 36107-1123
(334) 240-7243 ● 1-800-642-7761, Ext. 7243
Rick Pate
Commissioner
REQUEST FOR REPLACEMENT
PRIVATE APPLICATOR PERMIT
I hereby apply for a replacement Private Applicator permit to purchase and use restricted use pesticides pursuant
to Chapter 27, Title 2, Code of Alabama (1975) and Chapter 80-1-13, Alabama Administrative Code. I understand and
will comply with the provisions of the above statutes and rules, as well as product label instructions. Further, I
understand that any violation of the statutes, rules, or label instructions constitutes grounds for suspension or
revocation of permit, and other penalties.
PLEASE PRINT
____________________________________________________________
xxx-xx-
Last name
First Name
Middle Name
Last 4 of SSN
____________________________________________________________
________________________
Home Address
County
Date of Birth
____________________________________________________________
(_____)_________________
City
State
Zip Code
Telephone Number
____________________________________________________________
________________________
Email Address
Permit Number
➢ Mailing address:
{ } Same as above OR as follows:
__________________________________________________________________________________________
Street Address
City
State
Zip
➢ Along with this application, you must include a $5.00 check or money order payable to the Alabama
Department of Agriculture and Industries.
➢ MAIL TO:
Department of Agriculture and Industries
Pesticide Management ~ Private Applicator
1445 Federal Drive
Montgomery, AL 36107-1123
I understand that this permit is valid only for purchasing, using, or supervising the use of restricted use
pesticide(s) on property owned/leased/controlled by me or by a full-time employee for the purpose of producing
agricultural commodities. My signature is to attest that I have read and understand the rules and regulations of a private
applicator.
Signature of Applicant__________________________________________________
Date_____________________
-------------------------------------------FOR ADAI OFFICE USE ONLY----------------------------------------------
Permit Number
Reissue Date______________________________________________
CK/MO # _____________________________ Amt Paid $________
www.agi.alabama.gov
“We provide employment & services without discrimination.”