Application for Federal Pesticide Applicator Certification in Indian Country

INSTRUCTIONS FOR COMPLETING EPA FORM 8500­17­N 
AND PAPERWORK REDUCTION ACT NOTICE
This form is to be used to request certification to purchase and apply Restricted Use Pesticides in
Navajo Indian Country from the U.S. Environmental Protection Agency Region IX. 
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.
2. Enter your birth date using the numerical month­month­date­date­year­year format.
3. Enter your EPA Region 9 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 to Region IX for a pesticide applicator
certification in Navajo 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
state certificate or license”.
6a. Enter the two character abbreviation for the state in which you hold a valid certificate/license, the 
state applicator number, and the expiration date. Enter the code for the category or categories for
which you are certified/licensed by the state using the codes listed on the back of this instruction 
sheet. Use the code for the category that is an exact match to the category listed on your
certificate/license. Attach a photocopy of both sides of your state certification or license.
6b. If you do not hold a valid state applicator certificate and you are a private applicator, you may be
certified after completing the “Private Applicator Certification and Recertification Home Study 
Course” and related Questionnaire.
7. Sign and date the application and mail the application with a photocopy of both sides of your state
pesticide applicator certificate/license (if you are requesting certification based on state certification),
and a passport or digital photograph of yourself to:
Federal Plan Coordinator

Pesticides Office (CED­5)

U.S. EPA Region IX 

75 Hawthorne St.

San Francisco, CA 94105­3901

Paperwork Reduction Act Notice: This collection of information is approved by OMB under the
Paperwork Reduction Act, 44 U.S.C. 3501 et. seq. OMB Control No. 2070-0029. Responses to this
collection of information are mandatory 40 CFR 158. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. The public reporting and record keeping burden for this collection of
information is estimated 10 minutes per response. Send comments on the Agency’s need for this
information, the accuracy of the provided burden estimates and any suggested methods for minimizing
respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection
Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control
number in any correspondence. Do not send the completed form to this address.

INSTRUCTIONS FOR COMPLETING FORM 8500­17­N (CONTINUED)

Codes for Applicator Categories (6a.)
Category 

Code

Category 

Code

Agricultural Pest Control

1

Aquatic Pest Control

5

Agricultural Pest Control­Plant

1i

Right­of­Way Pest Control

6

Agricultural Pest Control­Animal

1ii

7

Forest Pest Control

2

Industrial, Institutional, Structural and Health Related Pest
Control
Public Health Pest Control

Ornamental and Turf Pest Control

3

Regulatory Pest Control

9

Seed Treatment

4

Demonstration & Research Pest Control

10

Arizona Department of Agriculture Specific Categories
Category 
Code
Right­of­Way pest control ­ Agriculture
6a
Regulatory pest control (Government ): M­44
9a
Regulatory pest control (Government ): Rodent 9c 
Fumigation – Agriculture (Private applicator) 
16

Arizona Structural Pest Control specific categories
Category
Code
B1
General Pest & Public Health
B2
Control of Wood Destroying Insects 
B3
Right of Way and Weed Control
Fumigation
B4
B5
Turf & Ornamental Horticulture
B7
Fungi Inspection
Wood Destroying Insect Inspection
B8
B9
Aquatic Pest Control

8

Utah specific categories
Category

Code

Aquatic­Surface Water 

5a

Aquatic­Sewer Root Control

5b

Structural & Health­Related

7

Regulatory 

9

Aerial Application
Vertebrate Animal

11
12

Fumigation/Stored Commodities 

13

Wood­Preservation

14

Wood Destroying Organisms 

15