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PMID - 03 Certified Pesticide Applicators

FPA pesticide application form for pesticide applicators

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Control No. ___________________

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APPLICATION FOR ACCREDITATION
APPLICATION FOR ACCREDITATION
CERTIFIED PESTICIDE APPLICATOR

Please check:

New

Agricultural Fumigator

Renewal

Agricultural Exterminator

Date of training/last symposium attended:

Venue :

Name
Email Address

Contact Number

Citizenship

Age
Educational Attainment

Company Name
Company Address

I hereby certify that the above information is correct to the best of my knowledge.

Signature
Requirements to be
attached to this
application

1.
2.
3.
4.

Certificate of attendance to training/symposium
Recently issued Certificate of Employment
Monthy Pest Control Operations Report (in-house/renewal)
List of Chemicals Used (Renewal)

PRIVACY NOTICE AND CONSENT TO USE DATA
We respect your privacy and keep your personal information confidential unless we are lawfully required or allowed
to disclose it or that you give your written consent to such disclosure.
FOR FPA USE ONLY:
Received by / Date:

:_________________

Official Receipt No.
____________________

Amount Paid

:_________________

Place

:_________________
 
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