Transcription of Pesticide Applicator Certification/Registration …
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Pesticide Applicator Certification/Registration …
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/Categories (Please check all that apply for certifi cation) Instructions on theback of this formBy signing below I certify that the foregoing is true and accurate to the best of my knowledge and belief and that I will comply with the provisions of 1994 Public Act 451, Part 83, as amended, and all regul
Title: Pesticide Applicator Certification/Registration Application Author: campbellt8 Subject: Pesticide Applicator Certification/Registration Application
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