: Answer questions 1-5 for each employee/applicant. Check
Yes or
No and enter the required
dates. Do NOT submit this application for employees who are not eligible. Employees must be registered within 75 days of
employment.
NON-COMMERCIAL CERTIFIED APPLICATORLICENSEE OR
REGISTRATION OF EMPLOYEE(S) WORKING UNDER THE SUPERVISION OF A
APPLICANT #1 FEE: $40.00 LOST OR STOLEN CARD FEE: $5.00
APPLICANT #2 FEE: $40.00
LOST OR STOLEN CARD FEE: $5.00
NORTH CAROLINA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
STRUCTURAL PEST CONTROL & PESTICIDES DIVISION
1090 MAIL SERVICE CENTER, RALEIGH NC 27699-1090
QUESTION
ANSWER
1. Has the applicant(s) completed the introductory
training workbook and 24 hours of on-the-job training
in the applicable phases?
Yes
No
Enter Training Date(s):
Yes
Attach the certificate(s) to this form.
No
___/___/_____ ___/___/_____
If no, then STOP HERE. The applicant is
not eligible. Do NOT submit at this time.
Introductory training is required.
2. Has the applicant(s) attended the Registered
Technician School or approved equivalent training?
If no, then STOP HERE. The applicant is
not eligible. Do NOT submit at this time.
The training must be completed before the
employee(s)/applicant(s) can apply.
Yes No
Unknown
If yes, enter the previous license/file number(s) here: ____________________
3. To your knowledge, has the applicant(s) ever had a
Registered Technician or Certified Applicator card
issued in North Carolina?
4. The applicant(s) will be working under your
supervision. Is your License or Non-Commercial
Certified Applicator (CA) card current and active?
Yes
No
Enter License Expiration Date:
____/____/______
If no, STOP HERE. The applicant is not
eligible. Your License or Non-Commercial
CA card must be current and active.
5. Are you aware a $40.00 fee is required for EACH applicant and that
the Registered Technician card expires on June 30 of each year?
Yes
Total Enclosed: $
Enter the FULL NAME of Employee/Applicant:
Social Security Number:
Hire Date:
Home Address:
Height: Weight: Hair Color:
Eye Color:
Job Title:
Date of Birth:
City: State:
Zip Code:
I hereby certify that none of the employees listed above have, within 3 years of the date of this application, been convicted of, plead guilty or nolo contendere, or
forfeited bond, in any state or federal court for a felony or any violation of the N.C. Structural Pest Control Law or to any regulation promulgated by the N.C.
Structural Pest Control Committee. In addition, I certify that the above employee(s) have received the required training prescribed by the Structural Pest Control
Committee for all registered technicians' identification cards applicants as provided in G.S. 106-65.29.
Enter the FULL NAME of Employee/Applicant:
Social Security Number: Hire Date:
Home Address:
Height:
Weight:
Hair Color:
Eye Color:
Job Title:
Date of Birth:
City:
State: Zip Code:
(Type or Print In Ink)
BUSINESS INFORMATION
Application is hereby made for Registered Technician Identification Card(s) for the above employee(s) working under the supervision of:
Signature:
________________________________________________________
(Licensee or Non-Commercial Certified Applicator)
License or Non-Commercial
Certified Applicator #: __________________
Company Name: ____________________________
County:___________________ Phone Number (______) _________________
Office Address: _____________________________________ ____________________ _____________________ _____ ________
(Street Address)
(Mail/P.O. Box)
(City) (State) (Zip Code)
Signature:
_____________________________________________________________________
Date: ____/____/_______
(Licensee or Non-Commercial Certified Applicator)
