Form 8500-17-N Request for Pesticide Applicator Certification in Navajo

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Form Approved. OMB Control No. 2070-0029. Approval Expires 12-31-2007

United States
Environmental Protection
Agency

US EPA Region IX
San Francisco, CA 94105

Request for Pesticide Applicator Certification in Navajo Indian Country
LAST NAME (+ Jr, Sr, II, III etc.)

FIRST NAME

MI

MAILING ADDRESS

CITY

STATE

ZIP + 4
–

AREA CODE

TELEPHONE

COUNTY

OFFICE USE

–

)
EMAIL ADDRESS (optional)

2. BIRTH DATE:

3. FEDERAL APPLICATOR ID # (if renewal):

4. CERTIFICATION TYPE:

9

Initial Certificate

5. APPLICATOR TYPE:

9

Commercial Applicator

9
9

Renewal/Recertification

9

R9
Replacement (Lost Card)

Private Applicator

6. CERTIFICATION METHOD:
a.

9 Requesting federal certificate based on valid state certificate or license. (Attach a copy of state certificate.)
State:

State Applicator Number:

Expiration Date:

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

b.

9 Self-study (ONLY for private applicators who do not hold state certification)

By signing this application below and submitting to U.S. EPA, I hereby attest to the fact that:
1. I have personally completed the EPA “Private Applicator Certification and Recertification Home Study Course Questionnaire.”
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;
and
4. 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
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-N

APP:

INIT:

SENT: