Fillable Central Licensing Test Taker Contact Form (Arizona)

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Central Licensing Test Taker Contact Form (Arizona)

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The Central Licensing Test Taker Contact Form (Arizona) form is 1 page long and contains:

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  • 37 check-boxes
  • 13 other fields

Country of origin: US
File type: PDF

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DOUGLAS A. DUCEY
Governor
Central Licensing
1688 W. Adams Street, Phoenix, Arizona 85007
(602) 542-3578 FAX (602) 542-0466
agriculture.az.gov
REV. 2020.08
MARK W. KILLIAN
Director
Test Taker Contact Form
Full Legal Name: _________________________________________________________________________________________
(REQUIRED - First Name, Middle Name, Last Name – NO INITIALS)
Mailing Address: ____________________________________________City: _______________ State: _______ ZIP: ________
Telephone Number: ____________________________________ E-Mail: _______________________________________
Date of Birth: _______________________________________ Social Security No.: ___________________________________
Certification No.: ___________________________________________ (if certified in Arizona)
What credential and category are you testing for? Check all that apply
Private Applicator (PUP): ☐ Core ☐ Fumigation
Commercial Applicator (PUC): ☐ Core ☐ AG Pest ☐ Seed Treatment
☐ Forest Pest ☐ Aquatic ☐ Rodent or M44 (Govt. only)
Golf Applicator (PUG): ☐ Core ☐ Ornamental & Turf ☐ Fumigation ☐ Aquatics
Responsible Individual (PRI): ☐ Core
Pest Control Advisor (PCA): ☐ Core ☐ Weed Control ☐ Insect & Mite Control
☐ Nematode ☐ Plant Pathogen ☐ Vertebrate Control
☐ Defoliation ☐ Plant Growth Regulators
Aerial Applicator (AAP): ☐ Core ☐ Aerial Applicator
Custom Applicator: ☐ Core ☐ Custom Aerial ☐ Custom Ground
Milk Sampler: ☐ Milk Sampler
Cottonseed Sampler: ☐ Cottonseed Sampler
Weighmaster: ☐ Public Weighmaster
Registered Service Representative (RSR): ☐ Fueling Meters - RSR ☐ Liquid Measuring Devices - RSR
☐ Small Scales - RSR ☐ Large Scales - RSR
☐ LPG (Propane) Meters – RSR ☐ Vapor Recovery - RSR
Have you taken and failed any of the exams listed within the preceding 12 months? ☐Yes ☐No
If yes, list all that apply:_______________________________________________________________________________________
__________________________________________________________________________________________________________
By signing below, I affirm that all information contained herein is true and correct
Signature: __________________________________________________________ Date: ________________________________
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Central Licensing Test Taker Contact Form (Arizona)

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Completed 12 August 2020

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