Florida Department of Agriculture and Consumer Services Division of Agricultural Environmental Services
APPLICATION FOR PEST CONTROL
EMPLOYEE-IDENTIFICATION CARD
ADAM H. PUTNAM |
Rule 5E-14.142, F.A.C. |
COMMISSIONER |
Telephone: (850) 617-7997 |
Remit Fee Online at: www.FreshFromFlorida.com
- or -
Check or Money Order Payable to
FDACS:
Bureau of Licensing and Enforcement
Revenue Processing Section
407 S. Calhoun Street, Room 121
Tallahassee, FL 32399-0800
This application must be legible and completely filled out. Copy this form as needed, but you must submit original signatures and the following:
(1)A CURRENT, clearly recognizable, full-faced head and shoulders photograph.
(2)A check or money order in the amount of $10.00 for each ID card made payable to “DACS”.
(3)A “Special Training to Perform Wood-Destroying Organism Inspections” affidavit (Form DACS-13642) MUST ACCOMPANY this application for applicants trained to perform Wood-Destroying Organism inspections and/or provide termite treatment(s) or re-inspection(s) for contractual purposes.
(4)A NEW applicant must submit his/her date of birth and a 4 digit Personal Identification Number (PIN) of His/Her choice. This combination creates a unique identifier for each person that cannot be changed. THE APPLICANT IS RESPONSIBLE FOR REMEMBERING HIS/HER PIN NUMBER.
_____ ID card application submitted AT THE TIME OF business license issuance – 002241 ($10)
_____ ID card application submitted with a BUSINESS LICENSE CHANGE – 001371 ($10)
(Change of Address, Change of Name or Change of Owner)
ATTACH RECENT 1 1/2 x 1 1/2 INCH CLEAR, FULL-FACE PHOTO HERE EVEN IF ALREADY ON FILE
DO NOT STAPLE
_____ ID card application submitted DURING the valid business license period – 002251 ($10)
Please issue a Pest Control Identification Card to the employee-applicant named below in accordance with Chapter 482.091, F.S., and Rule 5E-14, F.A.C.
Per Chapter 482.091(1)(b), F.S., the licensee and the certified operator in charge are jointly responsible for obtaining an identification card for employees within 30 days of employment. The postmark date of this application will be used to document and verify the employee’s work experience
for exam purposes.
1.NAME OF BUSINESS: ___________________________________________________________________JB Number: _____________________
BUSINESS LOCATION: ________________________________________________________________________________________________
(Street) |
(City) |
(Zip code) |
2.COMPLETE NAME OF EMPLOYEE: _______________________________________________________________________________________
--Please print or type-- |
(Last) |
(First) |
(Middle) |
HOME ADDRESS: ____________________________________________________________________________________________________ |
(Street) |
(City) |
(Zip code) |
DATE OF BIRTH: month _____________ |
day ___________ year ____________ 4 digit PIN #: ________________________________________ |
|
|
|
(Reference Memorandum #823 for explanation) |
This applicant began performing pest control services for this licensee on (DATE:) ___________________________________________
The primary pest control duties assigned to this employee are: __________________________________________________________
3.CHECK AND SIGN ONE STATEMENT ONLY:
(A)I am not currently employed at any other pest control licensee in Florida. If previously employed by a Florida licensee, please provide the
TERMINATION DATE: month _______ day ______ year _____ and your JE number: ____________________________________
(B)I am not currently employed at any other Florida pest control licensee and I will be a full time employee of the licensee performing the duties of the certified operator in charge of:
[circle all that apply] |
F |
G |
L |
T |
EFFECTIVE DATE: ________________________ CPO home/cell phone #: ______________________ |
(C)I am a certified operator currently employed at _________________________________________________________________
applying for a SECOND ID CARD for exam experience in [circle the appropriate category] F G L T
Original Signature of Applicant for ID card: _______________________________________________________ Date: ____________________
4.I DO HEREBY CERTIFY THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF. I ALSO CERTIFY THAT THE APPLICANT HAS RECEIVED AT LEAST 5 DAYS OF FIELD TRAINING UNDER THE DIRECT SUPERVISION OF A CERTIFIED OPERATOR AS REQUIRED BY SECTION 482.091(3), F.S.
______________________________________________________ JB/JF Number: _______________
Original Signature of Licensee or Certified Operator in Charge
_____________________________________________ |
___________________________________________________ |
(Please print Name) |
(Date) |
(Contact Phone number) |
FDACS-13606 Rev. 07/14
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