Pesticide Applicator Certification/registration Application
ADVERTISEMENT
1
2PI-232 (8/16)
Michigan Department of Agriculture and Rural Development
P.O. Box 30776, Lansing, MI 48909-8246 • 517-284-5653
In accordance with 1994 Public Act 451, Part 83
Pesticide
Applicator Certifi cation/Registration Application
Applicant (Applicator) Information
(Please print)
Name:____________________________________________________________________
First, middle initial, last
Home Address:_____________________________________________________________
Include apartment number if applicable
City:__________________________________________________ State: ______________
County:________________________________________________ Zip:_______________
Phone: (_____)_______________ Cell Phone: (_____)______________________________
Email:_____________________________________________________________________
Date of Birth: ____/____/______
Social Security Number:_______-____-____________
MM
DD
YYYY
Blank Space
1a. Are you applying for reciprocity?:
Yes
What state __________________
No
For Offi cial Use Only
1b. Are you certifi ed in, and a resident of, that state?:
Yes
No
Employer Information
Employer Name: ____________________________________________________________________________________________
Street Address of Employer:____________________________________________________________________________________
City:______________________________________________ State: _______ County: _____________________Zip:_____________
Phone: (_____)_____________ Fax: (_____)_______________ Email:_________________________________________________
Exams/Categories
(Please check all that apply for certifi cation)
1A
1B
1C
1D
2
2A
3A
3B
Private
Commercial
Registered
Field
Forest
Wood
Turfgrass
Vegetable
Fruit
Livestock
Ornamental
Core
Crops
Pest Mgmt.
Preservation
Core
Core
Crops
Crops
Pest Mgmt.
Pest Mgmt.
Pest Mgmt.
4
7E
5
5A
5B
5C
6
7A
7B
7D
7F
Wood
Seed
Interior Plant
Aquatic
Swimming
Microbial
Sewer Line
Right-of-Way
General
Vertebrate
Mosquito
Destroying
Treatment
Pest Mgmt.
Pools
Pest Mgmt.
Pest Mgmt.
Pest Mgmt.
Pest Mgmt.
Pest Mgmt.
Pest Mgmt.
Mgmt.
Pest Mgmt.
Application Fees
10
7G
9
(Non-refundable)
8
Domestic
Demo &
Regulatory
Public Health
Fumigation
Aerial
Animal
Research
Pest Mgmt.
Commercial Applicator $75
Pest Mgmt.
AOBJ: 0188
Pest Mgmt.
Pest Mgmt.
Private Applicator $50
AOBJ: 0343
Application Fees Exemption for honorably discharged veterans of the Armed Forces of the United States (private
pesticide certifi ed applicators only). A copy of your DD-214 must be submitted along with your application.
AOBJ: 0187
Commercial Registered Applicator $45
Private Registered Applicator $50
I am adding categories to my current certifi cation. Certifi cation Number:________________________
Application fee for adding categories is same as above.
By 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 regulations promulgated thereunder.
Payment 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:___________________
Instructions on the
Please print your name here:__________________________________________________________
back of this form
This certifi cation will NOT be issued without the above signature and date!
ADVERTISEMENT
0 votes
Related Articles
Related forms
Request For Pesticide Registry Or Pesticide Application Information - New York State Department Of Health
Legal
Form Doh-4212 - Emergency Pesticide Application Notification Exemption Reporting Form - New York State Department Of Health
Legal
Related Categories
Parent category: Business