Form AG-03030 "New Pesticide Applicator License Application" - Minnesota

What Is Form AG-03030?

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

Form Details:

  • Released on September 1, 2017;
  • The latest edition provided by the Minnesota 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 AG-03030 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Agriculture.

ADVERTISEMENT
ADVERTISEMENT

Download Form AG-03030 "New Pesticide Applicator License Application" - Minnesota

Download PDF

Fill PDF online

Rate (4.8 / 5) 16 votes
Pesticide & Fertilizer Management Division Ph. 651-201-6615 Fax 651-201-6105
New License Number:
20___NEW PESTICIDE APPLICATOR LICENSE APPLICATION
Minn Stat. Sec. 18B.33 & 18B.34
The data on this form will be used to process your application. You must provide your social security number (MS Sec 270C.72). We are required by law to collect this information and
we cannot grant your license without it. No one will have access to your social security number except those permitted access by law, your written consent, court order, or those
department employees whose job duties require access.
Applicator Information:
(Please print)
Last Name:
First Name:
MI:
Social Security Number:
Company Information:
Company Legal Name:
DBA (if different):
Company Street Address (No PO Box):
Company Mailing Address (if different):
Zip Code:
City:
Zip Code:
City:
State:
State:
Company Telephone:
County:
Financial Responsibility:
(Check all that apply)
Proof of Financial Responsibility is required by the MN Pesticide Control Law (Minn. Stat. Ch. 18B) for Commercial Pesticide Applicators only.
Liability Insurance
Net Asset Statement
Performance or Surety Bond
I am applying for a pesticide applicator license based on reciprocity. I hold a current pesticide applicator license and am a resident in the state
of _______________, license number_____________________, categories___________________, expires_____________________
Has applicant for license/certification ever had a license or certification denied, revoked or suspended by another state?
Yes
No
License Categories:
Categories M and S below are
(Check all that apply)
only available to Noncommercial
H - Seed Treatment
A - Core
N - Stored Grain & Fumigation
Pesticide Applicators:
I - Anti-Microbial
B - General Aerial
O - Soil Fumigation
J - Nat Areas, Frstry, Rghts Of Wy
C - Field Crops Pest Mgmt
P -Vertebrate Pest Control
M -
Food Processing
K - Ag Pest Cntrl - Animal
E - Turf and Ornamentals
Q - Wood Preservatives
Pest Control
L - Mosquito Control
F - Aquatic
R - Sewer Root Control
S - Noncommercial Structure
(Check one)
Type of License and Application Fees:
Commercial Pesticide Applicator
Noncommercial Pesticide
Noncommercial Government
Applicator
Pesticide Applicator
Application Fee:
$50.00
600306(3100)
Application Fee:
$50.00
600310(3100)
Application Fee:
$10.00
600314(3100)
ACRRA Surcharge:
ACRRA Surcharge:
$14.00
600339(3310)
$14.00
600339(3310)
Total Due:
$10.00
Total Due:
$64.00
Total Due:
$64.00
MINNESOTA DEPARTMENT OF AGRICULTURE
Return this form with your check made payable to:
ATTN: Cashier
625 Robert Street North
Licenses are NOT transferable and fees are not refundable.
Saint Paul, MN 55155-2538
I hereby certify that the information contained in and submitted with this form is true and correct.
For Office Use Only
Signature: ________________________________________
Date: ____________________
Name (Please print): ________________________________
Title: ____________________
Contact Telephone: ________________________ Fax Number: _______________________
E-mail Address: ______________________________________________________________
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request by calling 651-201-6000. TTY users can
call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
AG-03030 (9/17)
Date Computer Updated:__________________________
Pesticide & Fertilizer Management Division Ph. 651-201-6615 Fax 651-201-6105
New License Number:
20___NEW PESTICIDE APPLICATOR LICENSE APPLICATION
Minn Stat. Sec. 18B.33 & 18B.34
The data on this form will be used to process your application. You must provide your social security number (MS Sec 270C.72). We are required by law to collect this information and
we cannot grant your license without it. No one will have access to your social security number except those permitted access by law, your written consent, court order, or those
department employees whose job duties require access.
Applicator Information:
(Please print)
Last Name:
First Name:
MI:
Social Security Number:
Company Information:
Company Legal Name:
DBA (if different):
Company Street Address (No PO Box):
Company Mailing Address (if different):
Zip Code:
City:
Zip Code:
City:
State:
State:
Company Telephone:
County:
Financial Responsibility:
(Check all that apply)
Proof of Financial Responsibility is required by the MN Pesticide Control Law (Minn. Stat. Ch. 18B) for Commercial Pesticide Applicators only.
Liability Insurance
Net Asset Statement
Performance or Surety Bond
I am applying for a pesticide applicator license based on reciprocity. I hold a current pesticide applicator license and am a resident in the state
of _______________, license number_____________________, categories___________________, expires_____________________
Has applicant for license/certification ever had a license or certification denied, revoked or suspended by another state?
Yes
No
License Categories:
Categories M and S below are
(Check all that apply)
only available to Noncommercial
H - Seed Treatment
A - Core
N - Stored Grain & Fumigation
Pesticide Applicators:
I - Anti-Microbial
B - General Aerial
O - Soil Fumigation
J - Nat Areas, Frstry, Rghts Of Wy
C - Field Crops Pest Mgmt
P -Vertebrate Pest Control
M -
Food Processing
K - Ag Pest Cntrl - Animal
E - Turf and Ornamentals
Q - Wood Preservatives
Pest Control
L - Mosquito Control
F - Aquatic
R - Sewer Root Control
S - Noncommercial Structure
(Check one)
Type of License and Application Fees:
Commercial Pesticide Applicator
Noncommercial Pesticide
Noncommercial Government
Applicator
Pesticide Applicator
Application Fee:
$50.00
600306(3100)
Application Fee:
$50.00
600310(3100)
Application Fee:
$10.00
600314(3100)
ACRRA Surcharge:
ACRRA Surcharge:
$14.00
600339(3310)
$14.00
600339(3310)
Total Due:
$10.00
Total Due:
$64.00
Total Due:
$64.00
MINNESOTA DEPARTMENT OF AGRICULTURE
Return this form with your check made payable to:
ATTN: Cashier
625 Robert Street North
Licenses are NOT transferable and fees are not refundable.
Saint Paul, MN 55155-2538
I hereby certify that the information contained in and submitted with this form is true and correct.
For Office Use Only
Signature: ________________________________________
Date: ____________________
Name (Please print): ________________________________
Title: ____________________
Contact Telephone: ________________________ Fax Number: _______________________
E-mail Address: ______________________________________________________________
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request by calling 651-201-6000. TTY users can
call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
AG-03030 (9/17)
Date Computer Updated:__________________________