8500-17 Request for Pesticide Applicator Certification in Indian

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

–

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 8500-17

APP:

INIT:

SENT:

INSTRUCTIONS FOR COMPLETING EPA FORM 8500-17
PAPERWORK REDUCTION ACT NOTICE
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. The phone number
and address listed should be your business phone number and business address, if applicable. The phone
number should be one at which you can be reached during business hours. For commercial applicators,
both the address and phone number 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”. If contact information submitted on a previous
form is erroneous or outdated, please use the “Replacement (Lost Card)” option.
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 on-line
training course provided by EPA. A false statement in this certification, including regarding the
completion of training, may be grounds for denial of certification and may be punishable by fine or
imprisonment (U.S. Code, Title 18, Section 1001). Include documentation of completion of the
required training course(s).
To apply for recertification, complete one of the options described above during the 12 months preceding
the expiration of your current certificate.
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 page 2). To
determine the appropriate Regional office, see http://www2.epa.gov/aboutepa#pane-4.

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Addresses for Submitting Form
Note: To determine the appropriate Regional office, see http://www2.epa.gov/aboutepa#pane-4.
Region
Address
Region
Address
Federal Plan Coordinator
Toxics and Pesticide Unit
U.S. Environmental Protection Agency
Pesticides Program (OES05-4)
1445 Ross Avenue, Suite 1200
1
6
U.S. EPA - New England, Region 1
Pesticides Section (6PD-P)
5 Post Office Sq, Suite 100
Dallas, Texas 75202-2722
Boston, MA 02109-3912
U.S. Environmental Protection Agency,
Pesticide Applicator Certification
Region 2 Pesticides Team
Coordinator
Attn: Pesticide Certification Training
U.S. Environmental Protection Agency 2
Coordinator
7
Region 7
2890 Woodbridge Avenue
WWPD/TOPE/PEST
MS-500
901 N. 5th St
Edison, New Jersey 08837
Kansas City, KS 66101
US EPA, Region 8
Attn: Region 8 Certification
3
No Federally Recognized Tribes
8
1595 Wynkoop St, 8P-P3T
Denver, CO 80202
Federal Tribal Plan Coordinator
Federal Plan Coordinator
USEPA Region 4 - Pesticides Section
Pesticides Office (CED-5)
4
61 Forsyth Street SW
9
U.S. EPA Region IX
SNAFC - 12th Floor
75 Hawthorne St.
Atlanta, GA 30303
San Francisco, CA 94105-3901
Federal Pesticide Applicator Certification
U.S. Environmental Protection Agency
Program
ATTN: Pesticide Applicator Plan
Pesticides & Toxics Unit
5
Pesticide Program Section
10
US EPA, Region 10
77 W. Jackson Blvd. LC-8J
1200 Sixth Ave, Ste. 900, OCE-084
Chicago, IL 60604
Seattle, WA 98101

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 EPA-59 [77 FR
2060; January 12, 2012].

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