Form SPA-421 "Application for Structural Pest Control Advisory Committee" - Texas

What Is Form SPA-421?

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

Form Details:

  • Released on January 1, 2015;
  • The latest edition provided by the Texas Department of Agriculture;
  • 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 SPA-421 by clicking the link below or browse more documents and templates provided by the Texas Department of Agriculture.

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Download Form SPA-421 "Application for Structural Pest Control Advisory Committee" - Texas

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P.O. Box 12076 Austin, Texas 78711  (800) 835-5832  (512) 463-7476 
Hearing impaired: (800) 735-2988 voice  www.TexasAgriculture.gov
Texas Department of Agriculture
SPA-421
Application for Structural Pest
Control Advisory Committee
APPLICANT INFORMATION
Mr.
Mrs.
First Name
M. I.
Last Name
Ms.
Other
Primary Phone
Secondary Phone (optional)
(
)
-
Ext.
(
)
-
Ext.
E-mail
Birth Date (required)
/
/
month day
year
MAILING ADDRESS
Address
City
State
Zip
County
CATEGORY OF APPLICANT
1. Member who is an employee of a school district and associated with a school integrated pest management
program
2. Member representing public interest
3. Member from an institution of higher education knowledgeable in the science of pests and pest control
4. Member representing the interest of structural pest control operators
5. Member representing the interest of consumers
6. Member who is a structural pest control operator with experience in natural, organic or holistic pest control
SUPPORTING DOCUMENTATION
Please provide documentation to support the choice above. See instructions for more information.
Revised 01/01/2015
P.O. Box 12076 Austin, Texas 78711  (800) 835-5832  (512) 463-7476 
Hearing impaired: (800) 735-2988 voice  www.TexasAgriculture.gov
Texas Department of Agriculture
SPA-421
Application for Structural Pest
Control Advisory Committee
APPLICANT INFORMATION
Mr.
Mrs.
First Name
M. I.
Last Name
Ms.
Other
Primary Phone
Secondary Phone (optional)
(
)
-
Ext.
(
)
-
Ext.
E-mail
Birth Date (required)
/
/
month day
year
MAILING ADDRESS
Address
City
State
Zip
County
CATEGORY OF APPLICANT
1. Member who is an employee of a school district and associated with a school integrated pest management
program
2. Member representing public interest
3. Member from an institution of higher education knowledgeable in the science of pests and pest control
4. Member representing the interest of structural pest control operators
5. Member representing the interest of consumers
6. Member who is a structural pest control operator with experience in natural, organic or holistic pest control
SUPPORTING DOCUMENTATION
Please provide documentation to support the choice above. See instructions for more information.
Revised 01/01/2015
Application for Structural Pest Control Advisory Committee
Page 2 of 2
Applicant Name _______________________________________
CERTIFICATION STATEMENT
I hereby certify that all the information provided in connection with this application at any time is true and
correct to the best of my knowledge and agree that any misrepresentation or false statement made in
connection with this application will be grounds to disqualification of my application from consideration
to serve on the Structural Pest Control Advisory Committee.
I further certify that :
If applying as a “Member representing public interest”: I am not licensed under chapter 1951 of the
Occupations Code; and neither I nor my spouse:
• are registered, certified or licensed by an occupational regulatory agency in the field of pest
control;
• are employed or participated in the management of a business entity or other organization
regulated by or receiving funds from the Department;
• own or control, directly or indirectly, more than a 10 percent interest in a business entity or other
organization regulated by or receiving funds from the Department; or
• use or receive a substantial amount of tangible goods, services or funds from the Department,
other than compensation allowed by law for committee membership, attendance or expenses.
I am not an officer, employee or paid consultant of a Texas trade association in the field of pest control
(except for persons applying as “Member representing the interest of structural pest control operators”);
My spouse is not an officer, manager or paid consultant of a Texas trade association in the field of pest
control; and
I am not required to register as a lobbyist under Chapter 105 of the Government Code because of my
activities for compensation on behalf of a profession related to the operation of the Department.
I authorize the Texas Department of Agriculture to conduct a background investigation in relation to this
application.
I understand that TDA does not reimburse advisory committee members for expenses involved in serving
on the committee.
SIGNATURE
Applicant Name (print)
Applicant Signature
Date
/
/
month day
year
Revised 01/01/2015
INSTRUCTIONS FOR
APPLICATION FOR STRUCTURAL PEST CONTROL ADVISORY COMMITTEE
SECTION A
Applicant Information
A birth date is mandatory and will be used for the background check that is required to serve on the committee. This form
is available on our website www.TexasAgriculture.gov or by mail. Failure to provide a birth date will result in rejection
of your application. Enter the full legal name, mailing address and primary telephone number.
SECTION B
Category of Application
Check the appropriate box
SECTION C
Provide Supporting Documentation
See guidelines under each category type for the documentation needed. Attach additional pages or documents as needed.
1. Member who is an employee of a school district and associated with a school integrated pest management
program.
Please provide information on your experience with school integrated pest management programs and the name(s)
of the school districts(s) for which you are employed.
2. Member representing public interest.
Please provide information to demonstrate how your appointment would benefit the public interest.
3. Member from an institution of higher education knowledgeable in the science of pests and pest control.
Must have a post-graduate (master’s or doctorate) degree and be, at the time of appointment, employed in a
teaching capacity at an institution of higher education and have experience teaching courses that demonstrate that
the person is knowledgeable in the science of pests and pest control
4. Member representing the interest of structural pest control operators.
Based on recommendation by trade association of operators. Please provide any information to verify
recommendation by trade association of structural pest control operators.
5. Member representing the interest of consumers.
Please provide information to demonstrate your ability to represent the interests of consumers.
6. Member who is a structural pest control operator with experience in natural, organic, or holistic pest
control.
Please provide information to demonstrate your experience in structural pest control using natural, organic or
holistic pest control methods.
SECTION D
Certification Statement
Please read the certification statement carefully, and sign and date the application.
Mail to:
Texas Department of Agriculture
Attn: Structural Pest Control Service
Fax to: 888-232-2567
P.O. Box 12847
Austin, TX 78711-2847
Revised 01/01/2015
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