Change Of License Form - Texas Department Of Agriculture
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1
2COMMISSIONER SID MILLER
TEXAS DEPARTMENT OF AGRICULTURE
STRUCTURAL PEST CONTROL SERVICE
P.O. BOX 12847, AUSTIN, TEXAS 78711-2847
Phone: 877-542-2474 Fax: 888-232-2567
Internet Address:
Hearing Impaired: (800) 735-2988 (voice)
Change of License Form
***This form is NOT to be used to change a Business License or an Apprentice Card.***
Check Type of License to Be issued:
[ ]
Certified Applicator
[ ]
Technician
Check Type of Classification:
[ ]
Commercial
[ ]
Noncommercial
Must Indicate The Type of Change to be Made:
[ ] Change of Employer – If leaving current employer or changing branch office and going to work for different employer or branch office.
Complete All Sections. In Section B List the new employers information. Fees are based upon expiration date of new employer’s license and
insurance.
[ ] Additional License – If currently licensed and want another license issued at another location. Complete All Sections.
In Section B List the information of the employer you want the additional licensed issued to. Fees are based upon expiration date of additional
employer’s license and insurance.
[ ] Lost / Reprint License – If you lost a license or want a reprint. Complete All Sections.
[ ] Inactive Status – No longer employed with a pest control company or noncommercial entity. Complete Sections A & C. No charge unless a
duplicate license is wanted. To maintain license, must renew license yearly. See Section 593.6 of the SPCS Regs.
[ ] Address Change – Licensee’s residential/mailing address only. Complete All Sections.
[ ] Other- Explain:
Section A – MUST be completed by applicant (Print or Type)
Legal Name of Applicant
License #
Social Security No.*
Drivers License No.
Date of Birth
Home Location Address
Street
City
County
State
Zip
Home Mailing Address
Street
City
County
State
Zip
Home Tel. No. (
)
Home Email:
Effective Date of Change:
Section B – Must be completed if applicable (Print or Type)
Name of Company or Entity
TPCL #
If Applicable
Business Telephone No. (
)
Business Fax No. (
)
Bus Email:
Location Address:
Street
City
County
State
Zip
Mailing Address:
Street or PO Box
City
County
State
Zip
Section C – Must be completed by Applicant (Print or Type)
The Structural Pest Control Service performs criminal history searches on all license applicants and licensees, including those
applying for renewal of an existing license. At minimum, criminal history information is sought from the Texas Department of
Public Safety. This process may delay agency action on a license application, if the applicant's criminal history reveals an
arrest for, conviction of, or a plea of guilty to a criminal offense. If an applicant's or licensee's criminal history reveals a
conviction or plea of guilty to a criminal offense which relates to the occupation of structural pest control, the applicant will be
asked to submit additional information to demonstrate the applicant's current fitness to be licensed. Failure to submit the
requested information, submission of false or misleading information, or failure to demonstrate current fitness to be licensed
may result in denial of the application or revocation of an existing license.
FEE MUST BE INCLUDED TO PROCESS APPLICATION – See back of form to figure fees
SIGNATURE OF APPLICANT
DATE
Revised 1-1-15
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