Form Spc 001 – Fill Out and Use This PDF

SECTION A

1VERIFICATION INFORMATION

Full Legal Business Name

TDA Client No.

TDA License No. (TPCL)

SECTION B

SECTION C

Please provide only the information below that has changed.

1APPLICANT INFORMATION

Full Legal Business Name (owner’s name if sole proprietor – no aliases)

DBA (if applicable)

1CHANGE OF OWNERSHIP CANNOT BE REGISTERED WITH THIS FORM

If the tax identification number of your business has changed, a new application and fee is required. A new tax identification number indicates a change in ownership and the license does not transfer.

2OWNER, PRESIDENT, CEO, ETC.

	Mr.	Mrs.	First Name	M. I.	Last Name
	Ms.	____
Phone No.				E-mail
(	)	-	Ext.

3MAILING ADDRESS

Address

			City		State		Zip
	D		1 CHANGE IN RESPONSIBLE CERTIFIED APPLICATOR
			Name of new Responsible Certified Applicator (Please Print)
	SECTION
			Signature of new Responsible Certified Applicator (Required)
				Send completed form to:
				spcslicensing@texasagriculture.gov
				or FAX 1-800-909-8534

County

License Number (required)

Date

SECTION E

1CHANGE PERSON TO CONTACT FOR LICENSE-RELATED MATTERS

Mr.		Mrs.	First Name	M. I.		Last Name
Ms.		___
Title				Primary Phone
				(	)		-	Ext.
Secondary Phone (optional)				Fax (optional)
(	)	-	Ext.	(	)		-	Ext.
E-mail Address

***Important Note*** I understand that my email address is required for the Texas Department of Agriculture to keep me informed of critical information, including licensing and regulatory updates; renewal invoices; and other important communications. Failure to provide an email address may result in my not receiving time-sensitive information that could affect my compliance with state regulations, thereby, resulting in monetary penalties.

2MAILING ADDRESS

Address

	City	State	Zip	County

SECTION GSECTION F

1CHANGE LOCATION INFORMATION

Facility Name

2PHYSICAL ADDRESS OF LOCATION OF LICENSEE, LICENSED ACTIVITIES OR EQUIPMENT

Address (No P.O. Box)

City	State	Zip	County

Directions to Physical Location if address above is difficult to find

1SIGNATURE

By submitting changes to licensing information, the person submitting the changes certifies that he or she is authorized to make such changes on behalf of the licensee and that all information provided is true and correct to the best of the person's knowledge. Any misrepresentation or false statement made by the licensee or the licensee's authorized representative in connection with such changes, whether intentional or not, may result in denial, revocation, or non-renewal of any affected license and/or assessment of monetary administrative penalties.

Submitter’s Name (print)	Title
Submitter’s Signature (required)		Date (mm/dd/yyyy)
		/	/