Form P-28-1 "Application for Restricted Use Pesticide Dealer Representative License" - Hawaii

What Is Form P-28-1?

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

Form Details:

  • Released on February 17, 2015;
  • The latest edition provided by the Hawaii 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 P-28-1 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Agriculture.

ADVERTISEMENT
ADVERTISEMENT

Download Form P-28-1 "Application for Restricted Use Pesticide Dealer Representative License" - Hawaii

217 times
Rate (4.7 / 5) 11 votes
FOR DEPT. OF AGRICULTURE USE
Pesticides Branch
Qualification No.
1428 S. King Street
Date of Issue
Honolulu, HI 96814-2512
Expiration Date
http://hdoa.hawaii.gov/pi/pest
Exam Date
Receipt No.
APPLICATION FOR RESTRICTED USE PESTICIDE
DEALER REPRESENTATIVE LICENSE
PLEASE PRINT
1. Name of Applicant: ________________________________________________ Title: _______________________________
2. Name of Licensed Dealer: ______________________________________________________________________________
3. Business Address: ____________________________________________________________________________________
STREET
_________________________________________________________________________________________________
CITY
STATE
ZIP CODE
4
. Home Address: ______________________________________________________________________________________
STREET / P.O. BOX
_________________________________________________________________________________________________
CITY
STATE
ZIP CODE
5. Business Phone: _________________________________ 6. Business Fax: ____________________________________
7
8
. Cell Phone: ________________________
. E-mail Address:_________________________________________________
NOTE: The information you provide is considered public and may be released unless identified as “personal”. For item nos. 4,
7 & 8 (above), indicate any “personal” information (i.e., not related to the business) by circling the appropriate item number.
9. Employment Experience (past 5 years):
Company or Firm Name
Position or Title
From (mm/dd/yy) – To (mm/dd/yy)
************************************************************************************
STATEMENT
I declare under penalty of perjury, under the laws of the State of Hawaii, that the above information is true and correct.
_________________________________________________________ ___________________________
SIGNATURE
DATE
For examination scheduling, call contact the Education Specialist covering your district.
Honolulu Office
Hilo Office
Maui Office (covered by Honolulu)
Kauai Office (covered by Honolulu)
Ph. (808) 973-9409
Ph. (808) 974-4143
Ph. Maui State Toll Free Access:
Ph. Kauai State Toll Free Access:
Ph. (808) 973-9424
Cell (808) 333-2844
984-2400 ext. 39409 or 39424
274-3141 ext. 39409 or 39424
Fax (808) 973-9418
Fax (808) 974-4148
Fax (808) 873-3586 (Maui)
Fax (808) 241-7137 (Kauai Office)
Form P-28-1 Rev. 2/17/15
FOR DEPT. OF AGRICULTURE USE
Pesticides Branch
Qualification No.
1428 S. King Street
Date of Issue
Honolulu, HI 96814-2512
Expiration Date
http://hdoa.hawaii.gov/pi/pest
Exam Date
Receipt No.
APPLICATION FOR RESTRICTED USE PESTICIDE
DEALER REPRESENTATIVE LICENSE
PLEASE PRINT
1. Name of Applicant: ________________________________________________ Title: _______________________________
2. Name of Licensed Dealer: ______________________________________________________________________________
3. Business Address: ____________________________________________________________________________________
STREET
_________________________________________________________________________________________________
CITY
STATE
ZIP CODE
4
. Home Address: ______________________________________________________________________________________
STREET / P.O. BOX
_________________________________________________________________________________________________
CITY
STATE
ZIP CODE
5. Business Phone: _________________________________ 6. Business Fax: ____________________________________
7
8
. Cell Phone: ________________________
. E-mail Address:_________________________________________________
NOTE: The information you provide is considered public and may be released unless identified as “personal”. For item nos. 4,
7 & 8 (above), indicate any “personal” information (i.e., not related to the business) by circling the appropriate item number.
9. Employment Experience (past 5 years):
Company or Firm Name
Position or Title
From (mm/dd/yy) – To (mm/dd/yy)
************************************************************************************
STATEMENT
I declare under penalty of perjury, under the laws of the State of Hawaii, that the above information is true and correct.
_________________________________________________________ ___________________________
SIGNATURE
DATE
For examination scheduling, call contact the Education Specialist covering your district.
Honolulu Office
Hilo Office
Maui Office (covered by Honolulu)
Kauai Office (covered by Honolulu)
Ph. (808) 973-9409
Ph. (808) 974-4143
Ph. Maui State Toll Free Access:
Ph. Kauai State Toll Free Access:
Ph. (808) 973-9424
Cell (808) 333-2844
984-2400 ext. 39409 or 39424
274-3141 ext. 39409 or 39424
Fax (808) 973-9418
Fax (808) 974-4148
Fax (808) 873-3586 (Maui)
Fax (808) 241-7137 (Kauai Office)
Form P-28-1 Rev. 2/17/15