8500-17 Request for Pesticide Applicator Certification in Indian

^Please read instructions before completing form. Form Approved. OMB Control No. 2070-0029. Approval Expires 8/31/2026

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

COUNTY

OFFICE USE

EMAIL ADDRESS (optional)

2. BIRTH DATE:

M

M

–

D

D

–

Y

Y

3. FEDERAL APPLICATOR ID # (if renewal):

4. CERTIFICATION TYPE: ^{Initial Certificate}

Renewal/Recertification

Replacement (Lost Card)

5. APPLICATOR TYPE: ^{Commercial Applicator}

Private Applicator

6. CERTIFICATION METHOD: Please choose one certification method.

   1. Requesting federal certification based on valid federal, state or tribal certification or license. (Attach a copy of certification.)

^{Federal Agency, State, or Tribe (if applicable): ________________________} Applicator Number (if applicable):

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

Expiration Date:

M

M

–

D

D

–

Y

Y

2. Completion of EPA-administered private applicator training. This is ONLY for private applicators who do not have a valid state or tribal certification or license. (Attach a copy of completion of training.)

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. ^{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.

6. a. Commercial Applicators: By checking this box, I attest to follow all recordkeeping requirements in 40 C.F.R. Part 171.303(b)(7)(vi).

b. By checking this box, I attest my certification has not been suspended, modified, or revoked in the last 5 years by any federal agency, state, tribe, or territory.

If it has been suspended, modified, or revoked in the last 5 years, please check this box and attach an explanation.

c. By checking this box, I attest that I understand that I am responsible for following any tribal codes, laws, policies, regulations, etc. relevant to the application of pesticides, including Restricted Use Pesticides.

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:)

–

(

)

–

8. By completing this application, I understand that certain information will be posted to the EPA website, including, but not limited to, name and address. The information posted will be dependent on whether I am a commercial or private applicator https://www.epa.gov/pesticide-applicator-certification-indian-country/applicators-certified-under-epa-plan

9. 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:

APP:

INIT:

SENT:

EPA Form 8500-17

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 this is a certification renewal, check “Renewal/Recertification”. If contact information submitted on a previous form is erroneous or outdated (e.g., name change), 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 pesticide applicator 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 pesticide applicator 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 or email 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 3). To determine the appropriate Regional office and email address, see https://www.epa.gov/pesticide-applicator-certification-indian-country/regional-contacts-pesticide-applicator.

Addresses for Submitting Form

Note: To determine the appropriate Regional office and email address, see https://www.epa.gov/pesticide-applicator-certification-indian-country/regional-contacts-pesticide-applicator

Region	Address	Region	Address
1	U.S. EPA Region 1 RCRA, Waste Management, UST, & Pesticide Unit 5 Post Office Sq, Suite 100 Boston, MA 02109-3912	6	U.S. Environmental Protection Agency 1201 Elm Street, Suite 500, Pesticides Section (LCRD) Dallas, TX 75270
2	U.S. EPA Region 2 Pesticides Team Attn: Pesticide Certification Training Program, Chemicals Management Section 2890 Woodbridge Ave., MS-500 Edison, New Jersey 08837	7	Pesticide Applicator Certification Coordinator U.S. Environmental Protection Agency - Region 7 LCRD/TTPB 11201 Renner Blvd. Lenexa, KS 66219
3	U.S. EPA Region 3 Chemical Safety Program Branch LD40 Four Penn Center 1600 John F. Kennedy Blvd. Philadelphia, PA 19103	8	U.S. EPA, Region 8 Region 8 Pesticides Certification 1595 Wynkoop Street, 8LCR-CES Denver, CO 80202
4	Federal Tribal Plan Coordinator USEPA Region 4 - Pesticides Section 61 Forsyth Street SW, SNAFC-12th Floor Atlanta, GA 30303	9	Federal Plan Coordinator Pesticides Office Land 2-2 U.S. EPA Region IX 75 Hawthorne St. San Francisco, CA 94105-3901
5	U.S. EPA Region 5 ATTN: Pesticide Applicator Certification, LCRD/LCB/CMB 77 W. Jackson Blvd. LL-17J Chicago, IL 60604	10	U.S. EPA Region 10 Enforcement and Compliance Assurance Division, Air and Toxics Enforcement Section 1200 Sixth Avenue, Suite 155, 20-CO4 Seattle, WA 98101

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 is 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.

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].