Form Vpa 030 – Fill Out and Use This PDF

IMPORTANT INSTRUCTIONS:

1. Type or print clearly

4.

Put a blank space between each word

2.

Use 1 space for each letter or number

5.

Complete ENTIRE form (both sides, including signature)

3.

Always start in leftmost space

6.

Incomplete forms will be rejected

EXAM APPLICANT'S NAME AND ID INFORMATION

FIRST NAME

MI

LAST NAME

JR, SR, II etc.

Mo.

Day

Year

LAST 4 NUMBERS OF SSN

BIRTH DATE

EXAM APPLICANT'S MAILING ADDRESS

OPTIONAL ADDRESS LINE (For a business name, apartment complex name, etc)

STREET OR BOX #

CITY

STATE

ZIP CODE

TELEPHONE # AND PERSONAL IDENTIFICATION INFORMATION

EXAM CHOICES

Place an 'X' in the box next to the exams you want to take (maximum of 3)

COMMERCIAL CORE		DEALER		PRIVATE APPLICATOR
****************************COMMERCIAL CATEGORY EXAMS****************************
1A-AGRICULTURAL PLANT		7A-GENERAL & HOUSEHOLD PEST		8C-CAMPGROUND
1B-AGRICULTURAL ANIMAL				8D-COOLING WATER
		7B-TERMITES & OTHER WOOD
2-FOREST		DESTROYING INSECTS		8E-SEWER LINE ROOT CONTROL
3A-ORNAMENTALS		7C-FUMIGATION		8F-PET GROOMING
3B-TURF		7D-FOOD PROCESSING		9-REGULATORY
3C-INTERIOR PLANTSCAPE		7E-WOOD PRESERVING		10-DEMONSTRATION & RESEARCH
4-SEED TREATMENT		7F-ANTIFOULANTS		11-AERIAL
5-AQUATIC		8A-GENERAL PUBLIC HEALTH		12A-WATER SANITIZATION
6B-RIGHT-OF-WAY		8B-MOSQUITO		12B-STERILIZATION

EXAM SCHEDULING CHOICES ( From 'CERTIFICATION EXAM SCHEDULE' )

Must choose 3 different dates!

***************FIRST CHOICE************

***********SECOND CHOICE**************

************THIRD CHOICE***************

SITE CODE

MO.

DAY

YEAR

SITE CODE

MO.

DAY

YEAR

SITE CODE

MO.

DAY

YEAR

ATTENTION: YOU MUST COMPLETE THE OTHER SIDE OF THIS FORM!

OFFICE USE ONLY

NO

NO

NO

MO.

DAY

YEAR

EXAM SITE EXAM & TIME SHOW

EXAM & TIME SHOW

EXAM & TIME SHOW

DATE ASSIGNED

DATE REASSIGNED

EMPLOYER NAME AND TELEPHONE NUMBER

IF YOUR EMPLOYER IS A LICENSED PESTICIDE APPLICATOR BUSINESS OR PESTICIDE DEALER BUSINESS, PLEASE FILL IN THE

BUSINESS LICENSE NUMBER HERE

IN ALL CASES, PROVIDE ALL OF THE FOLLOWING INFORMATION

EMPLOYER NAME OR BUSINESS NAME (pesticide use-related only) IF NO CURRENT EMPLOYER OR BUSINESS, FILL IN YOUR NAME

	EMPLOYER OR BUSINESS MAIL ADDRESS
	IF NO CURRENT EMPLOYER OR BUSINESS, FILL IN HOME MAIL ADDRESS
STREET OR BOX #
CITY	STATE	ZIP CODE	COUNTY	USE
				COUNTY
				CODE
				BELOW

EMPLOYER OR BUSINESS PHYSICAL ADDRESS

IF NO CURRENT EMPLOYER OR BUSINESS, FILL IN HOME PHYSICAL ADDRESS

STREET

CITY

STATE

ZIP CODE

COUNTY

USE

COUNTY

CODE

BELOW

SIGNATURE BOX

SIGNATURE OF EXAM APPLICANT

EXAM APPLICATION FORM WILL BE REJECTED WITHOUT THIS SIGNATURE!!

NOTE: Providing false or misleading information on this form will result in denial or revocation of your certification and licensing.

			COUNTY CODES
01	- Atlantic County	08	- Gloucester County	15	- Ocean County
02	- Bergen County	09	- Hudson County	16	- Passaic County
03	- Burlington County	10	- Hunterdon County	17	- Salem County
04	- Camden County	11	- Mercer County	18	- Somerset County
05	- Cape May County	12	- Middlesex County	19	- Sussex County
06	- Cumberland County	13	- Monmouth County	20	- Union County
07	- Essex County	14	- Morris County	21	- Warren County
				22	– Out of State

State of New Jersey

Richard J.Codey	Department of Environmental Protection	Bradley M. Campbell
Acting Governor		Commissioner
	Pesticide Control Program
	PO Box 411
	Trenton, NJ 08625-0411

COMMERCIAL PESTICIDE APPLICATOR

CATEGORY TRAINING VERIFICATION FORM

PLEASE CHECK APPROPRIATE BOX BELOW:

YES, I HAVE COMPLETED THE 40 HOURS OF “ON THE JOB TRAINING” AND HAVE PERFORMED/WITNESSED THE MINIMUM NUMBER OF PESTICIDE APPLICATIONS REQUIRED BY NJAC 7:30-6.2. LIST CATEGORIES TRAINED IN BELOW:

___________________________________________________________________________

NO, I HAVE NOT COMPLETED THE 40 HOURS OF “ON-THE-JOB-TRAINING” BECAUSE IT IS NOT AVAILABLE. (Note: You may not use this option for categories 3A, 3B, 7A & 7B. Please see Notice and Category-Training Course List for these categories.)

Please explain below why training is not available:

APPLICANT’S NAME (print):______________________________________________________

APPLICANT’S SIGNATURE: _______________________________DATE: ________________

TRAINER: By signing below, I verify that the above named person completed 40 hours of on-the-job- training in the categories listed above as required by N.J.A.C. 7:30-6.2.

TRAINER’S NAME (print): _________________________________________________________

TRAINER’S PESTICIDE APPLICATOR LICENSE #: ____________________________________

TRAINER’S SIGNATURE: ______________________________________ DATE: _____________

Note: This form is for Commercial Pesticide Applicator licensing only. Please do not submit with Commercial Pesticide Operator application forms.

catrainingform 11/04

State of New Jersey

Richard J.Codey	Department of Environmental Protection	Bradley M. Campbell
Acting GOVERNOR		COMMISSIONER
	Pesticide Control Program
	PO Box 411
	Trenton, NJ 08625-0411
	“AFFIDAVIT”

I the undersigned attest that I have the required one-year of work experience in the following pesticide certification categories:

_______________________________________________________________________

Upon this Department’s request, copies of my pesticide application records, employer’s statements and any other proof as deemed necessary by the Department will be provided.

I hereby swear/affirm that the aforementioned statement is true to the best of my knowledge:

Print name: _____________________________________________________________

Signature: ___________________________________________ Date: ______________

Please Note: Only complete this affidavit if you have at least one year of work experience in the categories you are applying for. Do not send in the “Category Training Verification Form” when using this affidavit.

affidavit 2/05