Form Pa 409 – Fill Out and Use This PDF

The PA-409 form is a vital document issued by the Texas Department of Agriculture for the purpose of pesticide continuing education course recertification sponsorship. It encompasses applications both for new courses and renewals in agricultural and structural continuing education units (CEUs). For professionals seeking to either sponsor or update their educational courses in pesticide application, understanding and filling out the PA-409 form correctly is essential. Click the button below to learn more about filling out the form.

Get Form Now Download PDF

Form Pa 409 PDF Details

Understanding the intricacies of applying for pesticide continuing education courses in Texas is vital for sponsors looking to facilitate these critical training sessions. The PA-409 form serves as a crucial starting point in this process, administered by the Texas Department of Agriculture. It is designed for both new applications and renewals, covering a wide range of pesticide-related fields, including agricultural and structural pest control. The form requires detailed information from sponsors, including contact details, course information such as whether it will be open to the public, locations, dates, and the fees involved. Furthermore, it delves into the curriculum by asking the sponsor to list course topics, teaching methods, and instructor qualifications. These components ensure that the courses offered meet the standards set by the state for continuing education in pesticide application, underlining the importance of accuracy and comprehensiveness in the submission. Additionally, the form highlights the necessity of compliance with federal and state laws, including accessibility requirements under the ADA, emphasizing the broader regulatory framework within which these educational activities occur. By submitting this form, along with a course agenda and related documentation, sponsors play a pivotal role in maintaining public safety and environmental health through proper pesticide use and application.

Question	Answer
Form Name	Form Pa 409
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	pa_409_ceu_rece rtification_spo nsorship texas department of agriculture fillable form reg 202

Form Preview Example

P.O. Box 12847 Austin, Texas 78711 (877) 542-2474 (512) 463-7476 Hearing impaired: (800) 735-2988 voice www.TexasAgriculture.gov

	Texas Department of Agriculture
	Pesticide Continuing Education Course
TODD STAPLES, COMMISSIONER	Recertification Sponsorship

PA-409

1 TYPE OF APPLICATION

New Agricultural CEU Application

New Structural CEU Application

SEC.

Renewal Application for Agricultural Course No.

Renewal Application for Structural Course No.

1 SPONSOR INFORMATION

Sponsor Name

Agency

University

Business

Association

2 CONTACT PERSON

Mr.

Mrs.

First Name

M. I.

Last Name

Ms.

____

3 MAILING ADDRESS

SECTION

Address

City

State

Zip

4 CONTACT INFORMATION

Primary Phone

Secondary Phone (optional)

Fax (optional)

(

)

(

)

(

)

E-mail

Would you prefer to be contacted

Okay to post your e-mail address on

by e-mail?

Yes

TDA website?

Yes

1 COURSE INFORMATION

Will this course be open to the public?

Yes

SECTION

If yes, name of person to contact for more information:

_____________________________________

Phone number for more information (

)

Will a fee be charged?

Yes $

Amount

Will this course be for

One Location

Multiple Locations

Various Locations

This document becomes public record and is subject to disclosure. With few exceptions, you have the right to request and be informed about the information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. (Reference: Government Code, Sections 552.021, 552.023, and 559.004.)

Pesticide Division

Revised 4/16/2010

PA-409 Pesticide CEU Recertification Sponsorship

Page 2 of 4

Name

2 COURSE SITE AND DATE

)

Course Location

Address of Training

(cont.

City of Training

State of Training

Zip Code of Training

SEC. C

Date

(mm/dd/yy)

Time

Expected No. of Participants

To document additional course sites and dates, use supplemental form.

1 COURSE TOPICS FOR

Instruction

Demonstration

Proposed

TDA Approval

AGRICULTURAL CEUS

Hours

Credit

Safety Factors

Environmental Consequences

Pest Features

Business Ethics

Pesticide Factors

SECTION

Equipment Characteristics

Application Techniques

Biotechnology/Transgenic Crops

Total General (add 1-8)

10. Integrated Pest Management

11. Laws and Regulations

12. Label and Labeling

Comprehension (L&R)

13. Drift Minimization

14. Total Credits (add 9-13)

1 COURSE TOPICS FOR

Instruction

Demonstration

Proposed

TDA Approval

STRUCTURAL CEUS

Hours

Credit

General Standard Courses

Pest Control

Termite Control

SECTION

Lawn/Ornamental Insect Control

Commodity Fumigation

Structural Fumigation

Weed Control

Wood Preservation

14. Total Credits (add 1-8)

Pesticide Division

Revised 4/16/10

PA-409 Pesticide CEU Recertification Sponsorship

Page 3 of 4

Name

SEC. F

SECTION G

1METHOD OF INSTRUCTION (CHECK ALL THAT APPLY)

Lecture	Slide/Film/Video	Panel Discussion	Demonstration
Other (describe)	__________________________________

1INSTRUCTOR NO. 1 INFORMATION

Mr.	Mrs.	First Name	M. I.	Last Name
Ms.	____
Speaker Topic					Previously		Length of
Speaker Topic					Approved Speaker		Presentation
					Approved Speaker		Presentation
					Yes	No

2CONTACT INFORMATION

Primary Phone			Secondary Phone (optional)			Fax (optional)
(	)	-	(	)	-	(	)	-

1INSTRUCTOR NO. 2 INFORMATION

(cont.)G		Mr.	Mrs.	First Name
		Mr.	Mrs.	First Name
		Ms.	____
SECTION	Speaker Topic
SECTION	2 CONTACT INFORMATION
	2 CONTACT INFORMATION
	Primary Phone
	(	)	-

1INSTRUCTOR NO. 3 INFORMATION

(cont.)		Ms.	____	First Name
		Mr.	Mrs.	First Name
G
G
SECTION	Speaker Topic
SECTION	2 CONTACT INFORMATION
	2 CONTACT INFORMATION
	Primary Phone
	(	)	-

1INSTRUCTOR NO. 4 INFORMATION

FG(cont.)		Mr.	Mrs.	First Name
FG(cont.)

		Ms.	____
SECTION	Speaker Topic
SECTION	2 CONTACT INFORMATION
	2 CONTACT INFORMATION
	Primary Phone
	(	)	-

M. I.		Last Name
M. I.		Last Name

			Previously			Length of
			Approved Speaker			Presentation
			Yes	No
Secondary Phone (optional)					Fax (optional)
Secondary Phone (optional)					Fax (optional)
(	)	-			(	)	-
M. I.		Last Name


			Previously			Length of
			Previously			Length of
			Approved Speaker			Presentation
			Yes	No
Secondary Phone (optional)					Fax (optional)
Secondary Phone (optional)					Fax (optional)
(	)	-			(	)	-
M. I.		Last Name
M. I.		Last Name
			Previously			Length of
			Previously			Length of
			Approved Speaker			Presentation
			Yes	No
Secondary Phone (optional)					Fax (optional)
Secondary Phone (optional)					Fax (optional)
(	)	-			(	)	-

Pesticide Division

Revised 4/16/10

PA-409 Pesticide CEU Recertification Sponsorship

Page 4 of 4

Name

SECTION G (cont.)

1INSTRUCTOR NO. 5 INFORMATION

Mr.	Mrs.	First Name	M. I.	Last Name
Ms.	____

Speaker Topic					Previously		Length of
Speaker Topic					Approved Speaker		Presentation
					Approved Speaker		Presentation
					Yes	No

2CONTACT INFORMATION

Primary Phone			Secondary Phone (optional)			Fax (optional)
(	)	-	(	)	-	(	)	-

To document additional instructors, use supplemental form.

ATTACH AN AGENDA FOR THE COURSE TO THIS FORM

SECTION I

1SIGNATURE

I hereby certify ability to comply with any applicable federal and state laws, including the Americans With Disabilities Act (ADA) requirements for access to activities.

Applicant Name (print)	Title

Applicant Signature	Date	(mm/dd/yy)

SECTION J

1CHECKLIST

Please use this checklist to ensure you are sending all of the necessary information and documents.

Complete Pesticide CEU Recertification Sponsorship form

Include a course outline

Provide all supporting documentation

Submit at least 30 days prior to the first date of the course to:

Texas Department of Agriculture, Training and Certification Program, P.O. Box 12847, Austin, Texas 78711 or fax to : 888-216-9865.

Pesticide Division

Revised 4/16/10

Form Pa 409 – Fill Out and Use This PDF

Form Pa 409 PDF Details

Form Preview Example

Form Pa 409 isn’t the one you’re looking for?

Related Documents