QID Maryland Re-Certification Fullcredit Information Form

United States Department of Agriculture

National Agricultural Statistics Service

Maryland Field Office

Cooperating with the Maryland Department of Agriculture

RE-CERTIFICATION FULLCREDIT INFORMATION

MEETING NUMBER: 20210258

OMB No. 0535-NEW

Approval Expires: XX/XX/20XX

MD Certification ID Number: ( ) ( ) ( ) ( ) ( ) ( )

(Please PRINT name exactly as it appears on your registration card.)

Name:

Birth Date: (mm/dd/yy) / /

Address*:

*(only needed when applicator certification ID is unknown.)

Last 4 digits of the Social Security Number: ____________________

*(only needed when the applicator Certification ID is unknown)

CONFIDENTIALITY

All Maryland participants completing the 2022 Pesticide Survey and wishing to receive pesticide re-certification credit, must provide the above information. This is the same information asked for at a regular re-certification meeting.

By signing below, the certified applicator (or Enumerator agent) acknowledges that ONLY the information on this sheet will be given to the Maryland Department of Agriculture. And that the information will be used only for the purpose of granting a core re-certification credit. None of the actual survey data will be shared with that State agency.

Certified Applicator (or Enumerator) Signature*:

Signature Date

The information you provide will be used for statistical purposes only. Your responses will be kept confidential and any person who willfully discloses ANY identifiable information about you or your operation is subject to a jail term, a fine, or both. This survey is conducted in accordance with the Confidential Information Protection and Statistical Efficiency Act of 2018, Title III of Pub. L. No. 115-435, codified in 44 U.S.C. Ch. 35 and other applicable Federal laws. For more information on how we protect your information please visit: https://www.nass.usda.gov/confidentiality. Response to this survey is voluntary.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number is 0535-NEW. The time required to complete this information collection is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.