Pesticides Section

Application For Continuing Certification Credit Approval
*All Fields Are Required*

Date of Training:
Sponsoring institution or agency:
Contact person:
First Name: Last Name:

Mailing address of contact person:

EMAIL Address:


(must include email address to receive your confirmation)
P.O. Box or Street Address:
City:
County:
State: Zip:
Phone: ( ) Must Include Area Code:
Is this training open to the public? Yes *   No *
*If yes, it will be posted to the Pesticide Section's website.
Also, if you answer yes, go to the Training Calendar the following week on FRIDAY for confirmation of approval.

List any restrictions:

Location(s) of training:

Street Address:
City: County: (for NC only)
State:
Time training will begin: AM PM Format times in this manner... 12:00
Time training will end: AM PM Format times in this manner... 12:00
Title of training:
Please submit a detailed agenda including times of subject matter to be covered.
(you can copy & paste this info here from other formats or documents)
Length of time (hours)
directly related to pesticide
recertification credits:
This training is considered appropriate for Continuing Certification Credit in the following certification subclass or subclasses (check the square corresponding to the subclass code(s).
A. Aquatic K. Ag Pest - Animal P. Aerial Methods
B. Public Health L. Ornamental & Turf T. Wood Treatment
G. Forest M. Seed Treatment D. Dealer
H. Right-of-Way N. Demonstration & Research V. Private- Recert/Safety Class
I. Regulatory O. Ag Pest - Plant X. Private-Specialty Training
    All Subclasses except P and V

Instructor's Information:

Instructor's Name
Instructor's Title
Instructor's Education
Employed By*
*If not employed by Cooperative Extension Service or a Land-Grant Institution, a resume must be sent to verify qualifications.

*You may email the document here


2nd Instructor's Name
2nd Instructor's Title
2nd Instructor's Education
Employed By*
*If not employed by Cooperative Extension Service or a Land-Grant Institution, a resume must be sent to verify qualifications.

*You may email the document here


3rd Instructor's Name
3rd Instructor's Title
3rd Instructor's Education
Employed By*
 

*If not employed by Cooperative Extension Service or a Land-Grant Institution, a resume must be sent to verify qualifications. *You may email the document here

Training Materials:

Title:
Type: (Video, Slides, etc.)
Prepared or Distributed By:

I plan to prepare and submit the attendance roster using the Scanner & Database Program.

I plan to prepare and submit the attendance roster using the Online Method .