SPC&PD - Pesticide Application Form 8

Full page vector graphic layout of Form 8 Application

NORTH CAROLINA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES

STEVE TROXLER, COMMISSIONER

APPLICATION FOR LICENSE/CERTIFICATE RENEWAL

FORM#8

Form 038 Instructions and Routing
Form Number	Form Type	Mail To
038	Type: 038 PRIVATE PESTICIDE APPLICATOR TO BE ADDED
Instructions: The information that you provide will be used to prepare your certification card. Since you have passed your pesticide exam, you are eligible to be certified. Provide your county and phone number. Provide the farm name and farm mailing address. Sign on the line at the bottom of the page after reading the attestation statement. Answer the questions below as thoroughly as possible. Application should be returned with a check or money order in the amount of $10.00 made payable to NCDA&CS. PLEASE DO NOT SEND CASH.	Instructions: The information that you provide will be used to prepare your certification card. Since you have passed your pesticide exam, you are eligible to be certified. Provide your county and phone number. Provide the farm name and farm mailing address. Sign on the line at the bottom of the page after reading the attestation statement. Answer the questions below as thoroughly as possible. Application should be returned with a check or money order in the amount of $10.00 made payable to NCDA&CS. PLEASE DO NOT SEND CASH.	Mail To: NCDA&CS - Structural Pest Control & Pesticides Division Licensing Unit 1090 Mail Service Center Raleigh, NC 27699-1090 Phone: (919) 733-3556

Applicator and Farm Address Information
Applicator Col 1	Applicator Col 2	Applicator Col 3	Farm Col 1	Farm Col 2	Farm Col 3
Applicator:	Applicator:	Applicator:	Farm Name:	Farm Name:	Farm Name:
Mail Address:	Mail Address:	Mail Address:	Physical Address:	Physical Address:	Physical Address:
City:	State:	Zip Code:	City:	State:	Zip Code:
Date of Birth:	Date of Birth:	Date of Birth:	Home Phone:	Home Phone:	Home Phone:
Email:	Email:	Email:	Farm Phone:	Farm Phone:	Farm Phone:
Social Security #	-	-	County:	County:	County:

Operations and Certification Details
Question / Crop 1	Option 1 / Crop 2	Option 2 / Crop 3
For the Farm listed above do you serve as the: (please mark in the appropriate box)	For the Farm listed above do you serve as the: (please mark in the appropriate box)	For the Farm listed above do you serve as the: (please mark in the appropriate box)
Owner	Employee	Other (manager, family member, etc.)
Crops Grown: List crops grown(to which you apply pesticides) and the approximate acreage of the top three crops(in NC)	Crops Grown: List crops grown(to which you apply pesticides) and the approximate acreage of the top three crops(in NC)	Crops Grown: List crops grown(to which you apply pesticides) and the approximate acreage of the top three crops(in NC)
Crop 1:	Crop 2:	Crop 3:
Acreage:	Acreage:	Acreage:
Do you or your employer own or operate a farm, greenhouse, nursery, or timber production establishment in any other State?	Yes	No
If yes, which other state(s)?:	If yes, which other state(s)?:	If yes, which other state(s)?:
Certification: Have you ever been certified, or are you currently certified, in any other state?	Yes	No
If yes, which other state(s)?:	If yes, which other state(s)?:	If yes, which other state(s)?:
Do you or your employer provide housing to any employee(s) other than immediate family?	Yes	No

ONLINE EXAM IN-PERSON EXAM

DO NOT SEND CASH!!
DO NOT EMAIL FORM! Please mail form in with check or money order!!

ATTESTATION (Please Read & Sign Below):
By signing below, I hereby confirm that I am a producer of an agricultural commodity and that I understand my legal responsibilities for pesticide use in accordance with product labels and for direct supervision of all individuals making pesticide applications under my certification.

SIGNATURE REQUIRED

Fee: $10.00

X __________________________________________________
APPLICANT'S SIGNATURE