Attachment G - Form & Instructions for Use in Indian Country (8500-17-tbd)

Form Approved. OMB Control No. 2070-0029. Approval Expires xx-xx-xxxx

Please read instructions before completing form.

United States Environmental Protection Agency
Washington, D.C. 20460
Request for Pesticide Applicator Certification in Indian Country
LAST NAME (+ Jr, Sr, II, III etc.)

FIRST NAME

MI

MAILING ADDRESS

CITY

STATE

ZIP
–

AREA CODE

TELEPHONE

OFFICE USE

–

)

(

COUNTY

EMAIL ADDRESS (optional)

2. BIRTH DATE:

–
M

M

–
D

D

3. FEDERAL APPLICATOR ID # (if renewal):
Y

Y

4. CERTIFICATION TYPE:

Initial Certificate

Renewal/Recertification

5. APPLICATOR TYPE:

Commercial Applicator

Replacement (Lost Card)

Private Applicator

6. CERTIFICATION METHOD:
a.

Requesting federal certificate based on valid federal, state or tribal certificate or license. (Attach a copy of certificate.)

State (if applicable):

Applicator Number:

Expiration Date:
M

M

-

D

D

-

Y

Y

Applicator Category/Categories for which Certificate/License was Received (enter category code(s)):
b.

Completion of training (ONLY for private applicators who do not have a valid federal, state or tribal certificate or license)
By signing this application below and submitting to U.S. EPA, I hereby attest to the fact that:
1.

I have personally completed the required training.

2.

I understand and can apply the information therein.

3.

I understand the significance of labeling and understand my legal responsibilities for the use of pesticides in accordance with label instructions and warnings;

4.

and; I intend to purchase and use Restricted Use pesticides only for production of an agricultural commodity on property owned or rented by myself or my
employer or to other property if the application is made without compensation other than trading of personal services between producers of agricultural
commodities.

7. PLEASE SIGN HERE
I attest my certification has not been suspended or revoked in the last 4 years by any state, tribe, or territory. If it has been, please
check this box and attach an explanation.
A false statement in this certification may be grounds for denial of certification and may be punishable by fine or imprisonment
(U.S. Code, Title 18, Section 1001). I certify that all the statements that I have made on this form are true, complete and correct
to the best of my knowledge and belief, and are made in good faith.

SIGNATURE:

DATE SIGNED:

(FOR OFFICE USE:)
REC:

EPA Form 8500-17

APP:

INIT:

SENT:

INSTRUCTIONS FOR COMPLETING EPA FORM 8500-17
This form is to be used to request certification to purchase and apply Restricted Use Pesticides in Indian
Country from the U.S. Environmental Protection Agency.
1. Fill out all of the information. An email address is requested but is not required. Phone number listed
should be one at which you can be reached during business hours. The address should be your business
address, if applicable, for commercial applicators since this information will be posted to EPA's website.
2. Enter your birth date using the numerical month-month-date-date-year-year format.
3. Enter your EPA Federal Applicator Identification number if this is a renewal or request for a
replacement card.
4. Certificate Type: Check appropriate box. If this is your first application for a pesticide applicator
certification in Indian Country, check “Initial Certificate”.
5. Applicator Type: Check “Private Applicator” ONLY if you will be or are applying pesticides for
production of an agricultural commodity on property owned or rented by you or your employer. All other
applicators check “Commercial Applicator”. There is no “noncommercial” or “public” federal applicator
type.
6. Certification Method: In most cases you will check “Requesting federal certificate based on valid
federal, state or tribal certificate or license”.
6a. Enter the two character state for which you hold a valid certificate/license, if applicable, the applicator
number for your existing certificate, and expiration date. Enter the code for the category or categories for
which you are currently certified/licensed. Attach a photocopy of both sides of your current and valid
federal, state or tribal certification or license. The underlying certificate needs to come from a state or
tribe that shares a contiguous boundary with the area of Indian country in which you intend to apply
RUPs.
6b. If you do not hold a valid federal, state or tribal applicator certificate and you are applying to be a
private applicator, you may be certified after submitting documentation of completion of the equivalent of
40 hours of classroom or workshop training, 40 hours of coursework, or accumulation of 40 continuing
education units (CEUs) of pesticide applicator training or equivalent material. The documents showing
completion of training submitted with this application must be from state-approved training courses. At
least 10 hours of the CEUs, coursework or training must include the general standards of competency
outlined in 40 CFR 171.5 and 40 CFR 171.6. Courses that cover the material outlined in 40 CFR
171.4(b) are also appropriate because they overlap with the material covered in 40 CFR 171.5 and 40
CFR 171.6. Training must be completed within the two years prior to certification. These topics are
typically covered in state prelicense courses and by cooperative state extension service sponsored
training. Any CEUs, coursework or training not specifically covering the general standards for
competency must be in the agricultural plant or animal categories or related to agricultural production. If
you have questions about what courses are applicable, please contact the appropriate Regional office (see
addresses on page 3). To determine the appropriate Regional office, see
http://www.epa.gov/epahome/whereyoulive.htm . Include documentation of completion of the
required training course(s).

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To apply for recertification, you must complete 6 CEUs of pesticide applicator training or equivalent
material during the four-year certification period, with 3 CEUs occurring in the year preceding
recertification. Any CEUs, coursework or training not specifically covering the general standards for
competency must be in the agricultural plant or animal categories or related to agricultural production.
The documents showing completion of training submitted with the recertification form must be from
state-approved training courses.
7. Sign and date the application and mail the application with a photocopy of both sides of your existing
federal, state, or tribal pesticide applicator certificate/license (if you are requesting certification based on a
federal, state, or tribal certification) to the appropriate Regional office (see addresses on pages 2 and 3).
To determine the appropriate Regional office, see http://www.epa.gov/epahome/whereyoulive.htm
Paperwork Reduction Act Notice: The public reporting burden for respondents completing this form is
estimated to average about 10 minutes per response. Send comments (referencing OMB Control Number
2070-0029 and EPA Form 8500-17) about the burden estimate or any other aspect of this collection of
information, including suggestions for reducing the burden to: Director, Collection Strategies Division
(2822T), U.S. Environmental Protection Agency, 1200 Pennsylvania Ave., N.W., Washington, D.C.
20460. Do not send your completed application form to this address.
Privacy Act Statement: Title 7 United States Code, section 136i(a)(1) authorizes the collection of this
information. The primary use of this information is to identify persons certified by EPA under the
Agency’s federal certification plan which administers and oversees certification of applicators of
restricted use pesticides. Disclosures of this information may be made pursuant to published routine uses,
including to appropriate agencies for law enforcement purposes and to an EPA website for information
purposes. Providing the requested information is voluntary, but failing to do so may result in EPA’s
inability to approve your request to become, or maintain your status as, a certified applicator of restricted
use pesticides. For a full description of this system notice, including routine uses, see [insert FR Notice
citation upon publication].

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Addresses for Submitting Form
Region
Address
Federal Plan Coordinator
Toxics and Pesticide Unit
Pesticides Program (OES05-4)
1
U.S. EPA - New England, Region 1
5 Post Office Sq, Suite 100
Boston, MA 02109-3912
U.S. Environmental Protection Agency, Region 2
Pesticides Team
Attn: Pesticide Certification Training Coordinator
2
2890 Woodbridge Avenue
MS-500
Edison, New Jersey 08837
3
No Federally Recognized Tribes
Federal Tribal Plan Coordinator
USEPA Region 4 - Pesticides Section
4
61 Forsyth Street SW
SNAFC - 12th Floor
Atlanta, GA 30303
U.S. EPA
Land and Chemicals Division, CMB
5
77 W. Jackson Blvd. LC-8J
Chicago, IL 60604
U.S. Environmental Protection Agency
1445 Ross Avenue, Suite 1200
6
Pesticides Section (6PD-P)
Dallas, Texas 75202-2722
Pesticide Applicator Certification Coordinator
U.S. Environmental Protection Agency - Region 7
7
WWPD/TOPE/PEST
901 N. 5th St
Kansas City, KS 66101
US EPA, Region 8
Attn: Region 8 Certification
8
1595 Wynkoop St, 8P-P3T
Denver, CO 80202
Federal Plan Coordinator
Pesticides Office (CED-5)
9
U.S. EPA Region IX
75 Hawthorne St.
San Francisco, CA 94105-3901
Federal Pesticide Applicator Certification Program
Pesticides & Toxics Unit
10
US EPA, Region 10
1200 Sixth Ave, Ste. 900, OCE-084
Seattle, WA 98101

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