Agr Form 702 4280A – Fill Out and Use This PDF

OFFICE USE ONLY

CASHIER USE ONLY

ISSUED:__________________________

Pesticide Management Division

2014 PESTICIDE/SPI

PO Box 42591

Olympia, WA 98504-2591

LICENSE RENEWAL APPLICATION

Toll Free 877-301-4555

E-mail: license@agr.wa.gov

Except where noted, all licenses expire 12/31/14.

INSTRUCTIONS

(1) Mark license(s) you wish to renew in Section 1. Note: WSDA now has an online renewal option. See website for details.

(2) Determine fee. Renewals submitted after January 1 require the penalty fee in addition to the license fee indicated or

completion of the penalty fee exemption statement at the bottom of this form.

(3) Fee for Structural Pest Inspector license is not required if renewing any one of the ive license types in bold (the license

types listed above Structural Pest Inspector).

(4) Select Application Method (if applicable). Complete Section 2 --

Applicant Information.

(5) Instruct WSDA how you would like to be notiied when your license is updated by completing Section 3.

(6) Please send completed form with appropriate fee to WSDA at the address above.

SECTION 1 – LICENSES TO RENEW

RENEWAL FEE

LICENSE TYPE

EXPIRES

FEE PENALTY FEE*

 Commercial Operator

12/31/13

$67

$67

TOTAL LICENSE FEE(S)

$ ______________________

 Private Commercial

.........................

12/31/13

$33

$33

7101

 Commercial Consultant

12/31/13

$60

$60

PENALTY FEE(S)

$ ______________________

 Public Consultant

12/31/13

$33

$33

7102

 Demo & Research

12/31/13

$33

$33

TOTAL REMITTANCE

$ ______________________

 Structural Pest Inspector**

12/31/13

$60

$60

Make checks payable to WSDA. Please do not send cash.

 Dealer Manager

12/31/13

$33

$33

Checks returned by the bank will be charged a handling

 Public Operator

12/31/13

$33

$33

fee of $25.00 (RCW 62A.3.515(a) and 62A.3.520.).

 Private Applicator (PA)

12/31/13

$33

$33

APPLICATION METHOD

 Limited Private Applicator (LPA)

5 years

$33

$33

 Rancher Private Applicator (RPA)

5 years

$100

$25

(Check all that apply)

(Note: No fee required for PA, LPA or RPA license if renewing

 AIR  GROUND

 CHEMIGATION

any other WSDA pesticide license for which a fee is paid.)

Do you apply fertilizers through irrigation equipment? Yes

**see instructions #3 above

*see instructions #2 above

SECTION 2 – APPLICANT INFORMATION

NAME (Last, First, Middle) PLEASE PRINT CLEARLY

SOCIAL SECURITY NUMBER

LICENSE NUMBER

BIRTHDATE

(Required)

MONTH

DAY YEAR

HOME MAILING ADDRESS (PO Box or Street Address)

E-MAIL ADDRESS

HOME TELEPHONE NO.

(

)

CITY

STATE

ZIP CODE

COUNTY

COMPANY / AGENCY NAME

COMPANY/AGENCY TELEPHONE NO.

(

)

SECTION 3 – LICENSEE NOTIFICATION

 Yes, I need a new plastic card

Notify me of license update by (mark one only):

 E-mail (be sure to neatly print e-mail address in Section 2 above)

 Postal mail

 None. I will periodically check the WSDA website at agr.wa.gov/PestFert/LicensingEd/Search/

PENALTY FEE EXEMPTION STATEMENT

DECLARACIÓN DE EXCEPCIÓN DE PAGO DE MULTA

If you are applying for a renewal after January 1 and you have not performed

Si usted está solicitando renovar su licencia después de 1ro de enero y no realizado

work requiring your license(s), you are exempt from the penalty fee. You must

ningún trabajo que requería su(s) licencia(s), usted está excepto de pagar la multa.

sign the statement below verifying your exemption status.

Usted debe irmar la siguiente declaración para veriicar su estatus de excepción.

I hereby state that I have not operated as a

Yo declaro por este medio que no he operado

__________________________________________________________

_________________________________________________________________

LIST ALL LICENSES FOR WHICH THIS EXEMPTION APPLIES

ANOTE TODAS LAS LICENCIAS QUE CALIFICAN PARA ESTA EXCEPCIÓN

since the expiration of my last license and am therefore exempt from the penalty fee(s).

desde la expiración de mi licencia, y por tanto, estoy excepto de pagar la(s) multa(s).

__________________________________________________________

_________________________________________________________________

SIGNATURE OF APPLICANT

DATE

FIRMA DEL SOLICITANTE

FECHA

LICENSE TYPE

DEFINITIONS

Commercial Operator

A person employed by a commercial applicator to apply pesticides to the land of

Fee: $67.00

another. This land can either be publicly or privately owned. The commercial

operator license is not valid unless working for a licensed commercial applicator.

Commercial Applicator

A person engaged in the business of applying pesticides to the land/property of

Fee: $215.00

another. This land can either be publicly or privately owned.

NOTE: Use "Commercial Pesticide Applicator License Application" (AGR

702-4241) to apply for this license.

* Structural Pest Inspector

A person who inspects a structure for wood destroying organisms or conditions

Fee: $60.00

conducive to their development. Wood destroying organisms include carpenter

and moisture ants, termites, wood infesting beetles and wood rot (fungus). This

license is required in addition to any license needed to apply, consult or

distribute pesticides. Proof of inancial coverage required. Go to http://agr.wa.gov/

PestFert/LicensingEd/CaSpiInfo.aspx for further information.

Private-Commercial Applicator

A person who applies or supervises the use of a "restricted use" pesticide on

Fee: $33.00

land owned or rented by him or his employer for purposes other than the production

of an agricultural commodity.

Dealer Manager

A person who supervises the distribution of pesticides (other than home and gar-

Fee: $33.00

den products) from a pesticide dealer outlet. The dealer manager license is not

valid unless working for a licensed Pesticide Dealer outlet.

** Public Operator

A person who, while acting as an employee of a governmental agency, applies

Fee: $33.00

"restricted use" pesticides by any means or general use pesticides by power

equipment on public or private property. The public operators license is not valid

unless working for a public agency.

Fee: $33.00

supplies technical advice, supervision, aid or makes recommendations to any

user of non-home and garden pesticides. The public pest control consultant license

is not valid unless working for a public agency.

Commercial Pest Control

A person who sells or offers pesticides for sale at other than the licensed pesti-

Consultant

cide dealer outlet from which they are employed. In addition, commercial consultants

Fee: $60.00

may offer or supply technical advice, aid, or make recommendations to the users

of non-home and garden pesticides. Licensed and employed commercial applica-

tors and commercial operators may act as commercial consultants without acquiring

the license.

Demonstration & Research

A person who applies or supervises the use of any experimental use pesticide or

Fee: $33.00

any "restricted use" pesticide at no charge to small experimental plots for re-

search purposes.

Private Applicator

A person who applies or supervises the use of any pesticide through chemigation

Fee: $33.00

equipment or a "restricted use" pesticide on land owned or rented by him

or his employer for the purpose of producing an agricultural commodity.

No fee required if applicant pays for another qualifying WSDA pesticide license.

Limited Private Applicator

Both licenses allow holder to apply or supervise the use of restricted use

Fee: $33.00

herbicides on non-production agricultural land (pastures, rangeland, areas around

Rancher Private Applicator

farm buildings) and in mixed rangeland-timber areas to control weeds designated

Fee: $100.00

for mandatory control. Rancher Private Applicators may also apply herbicides and

rodenticides to limited production agricultural land where hay and grain are

grown primarily for on-farm use. Neither license allows the use of restricted use

insecticides, fungicides or aquatic herbicides. No fee required for either license

if applicant pays for another qualifying WSDA pesticide license. Both are valid in

Eastern Washington only.