North Carolina Department of Agriculture and Consumer Services
Structural Pest Control & Pesticides Division
1090 Mail Service Center
Raleigh, North Carolina 27699-1090
Branch Office Registration Form
(Type of Print in Ink)
Licensee Information:
Licensee License No.
Company Name Telephone No.
Address of Licensee's Home Office (street or RFD) Facsimile No.
(P.O. Box) Address of Primary Residence
(State & zip code)
State & zip code
Branch Office Information:
Location of Office (Street address) Mailing address (if different from location information)
(Suite or Office No.) (City)
(City) (State & zip code)
(State & zip code) Distance, in miles, from primary residence: Telephone No.
Location at which records and pesticides will be maintained (Check one)
Home Office Branch Office
Designated Certified applicator(s): (list all if more than one)
Name Certification No.
Name Certification No.
Name Certification No.
Employees working from branch office:
CA or RT
Card No.
CA or RT
Card No.
I hereby certify that the above information is true and correct.
Licensee's Signature: Date: