National Form For Use in Indian Country

Form Approved. OMB Control No. 2070-0029. Approval Expires 02-28-2015

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

–

Y

3. FEDERAL APPLICATOR ID # (if renewal):

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):
Expiration Date:

Applicator Number:

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 7100-01

APP:

INIT:

SENT: