Transcription of Pesticide Applicator Certification/Registration Application
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Pesticide Applicator Certification/Registration Application
Blank SpaceFor Offi cial Use OnlyPayment Method: Check/Money Order No. _____ Amount enclosed: _____Please make check/money order payable to the State of michigan (see instructions on back of form).Signature:_____ Date:_____Please print your name here:_____Michigan Department of Agriculture and Rural Box 30776, Lansing, MI 48909-8276 517-284-5653 Name:_____Home Address:_____City:_____ State: _____ County:_____ Zip:_____ Phone: (_____)_____ Cell Phone: (_____)_____ Email:_____Date of Birth: ____/____/_____ Social Security Number:_____-____-_____1a. Are you applying for reciprocity?: Yes What state _____ No 1b. Are you certifi ed in, and a resident of, that state?: Yes No Employer InformationEmployer Name: _____Street Address of Employer:_____City:_____ State: _____ County: _____Zip:_____Phone: (_____)_____ Fax: (_____)_____ Email:_____Application Fees (Non-refundable) Pesticide Applicator Certifi cation/Registration ApplicationIn accordance with 1994 Public Act 451, Part 83 PI-232 (5/17)Exams/Categ
pesticides or apply pesticides by aircraft. Registered applicators must pass the commercial core exam, and complete a Michigan Department of Agriculture and Rural Development (MDARD) approved training program coordinated by an MDARD approved trainer. The training program must be verifi able and category-specifi c.
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