Fillable INSTRUCTIONS FOR COMPLETING THE CERTIFIED APPLICATOR'S CARD APPLICATION (Information Technology Services)

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INSTRUCTIONS FOR COMPLETING THE CERTIFIED APPLICATOR'S CARD APPLICATION (Information Technology Services)

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Revised 02/02/2011
INSTRUCTIONS FOR COMPLETING THE
CERTIFIED APPLICATOR'S CARD APPLICATION
APPLICANT INFORMATION
Complete all personal information for the applicant. Be sure to include the Job Title.
COMPANY / EMPLOYER INFORMATION
The company’s name and address with which you are currently employed. For commercial Certified
Applicator this will be a pest control company. For non-commercial CAs, the company name may not be
a pest control company. For unemployed CAs, leave this information blank.
CERTIFIED APPLICATOR CARD INFORMATION
Check the appropriate box for New Card, New Phase added to existing card, Transfer of Card from one
employer to another, or Replacement of a lost card. All commercial certified applicator applications must
be signed by the licensee.
Check the box for the phase(s) to be included or added to the card. Include the test date(s) if known.
The Division issues certified applicator’s cards in three types:
Commercial: Individuals working under the supervision of a licensee and charging a fee for the
pest control services they perform.
Noncommercial: Individuals that are employed by a company (that is not a pest control company)
who performs their company’s pest control services. Noncommercial individuals cannot hire
themselves out or trade pest control services.
Unemployed: Individuals that are not currently engaged in the pest control business, but want to
maintain their certification.
LICENSEE INFORMATION
This section applies only to a certified applicator employed with a person holding a structural pest control
license.
RESIDENT AGENT INFORMATION
This section applies only to a certified applicator that resides outside of North Carolina. The resident
agent should be located at the home office location of the licensee or, for a noncommercial CA, at the
company location in North Carolina.
FEES SUBMITTED
Fees required are listed on the front of the form. Be sure to indicate the amount paid and to include your
check or other form of payment with the application. Applications received without payment will be
returned. Mail applications with fees to: NC Department of Agriculture (NCAGR & NC)
1090 Mail Service Center
Raleigh, NC 27699-1090
BRANCH OFFICE INFORMATION
This information is required ONLY if the certified applicator is to be the designated certified applicator in a
branch office location other than the LICENSEE'S home office. The term Home Office means the office to
which the employing LICENSEE'S license is assigned NOT the corporate office.
APPLICANT, EMPLOYER AND RESIDENT AGENT CERTIFICATION
All applicable individuals must sign the application. Unsigned applications will be returned.
Revised 12/30/13
NORTH CAROLINA DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES
STRUCTURAL PEST CONTROL DIVISION, 1090 Mail Service Center, Raleigh, NC 27699
APPLICATION FOR STRUCTURAL PEST CONTROL CERTIFIED APPLICATOR'S
CARD
(Type or Print in Ink)
APPLICANT INFORMATION
Applicant's Name:
Social Security Number:
Home Address:
Job Title: Circle Applicable title
City
State
Zip
Home Telephone Number:
Date of Birth:
Height
Weight
Hair Color
Eye Color
BUSINESS/EMPLOYER INFORMATION
Company Name:
Telephone Number:
Street Address
Mailing address different from street address)
City
State
Zip
County
City
State
Zip
County
CERTIFIED APPLICATOR CARD INFORMATION
This application is for a: (Check the applicable
box. For transfers, indicate the last day of
employment with previous employer):
New CA Card
New CA Phase
Transfer of Card
(effective date)
____________
Replacement Card
Address Change
Check certification phase(s) and card type for
which application is being made (see instructions
on back):
P (Household Pest) ________________
Test Date
W (Wood-Destroying Organism) _________
Test Date
F (Fumigation) _________
Test Date
Circle: Commercial
Noncommercial
Unemployed
LICENSEE INFORMATION (FOR COMMERCIAL CERTIFIED APPLICATORS ONLY)
Licensee's Name Licensee’s Signature
License Number
RESIDENT AGENT INFORMATION
If you are not a resident of North Carolina you must designate a resident agent. The resident agent's address must be
the same as the company address.
Resident Agent's Name:
Telephone Number:
Address:
City
State
Zip
County
FEES SUBMITTED
The fee for a new Certified Applicator
Card is $50.00
The fee for a transfer, duplicate or
new phase is $5.00
Enter total fee enclosed:
BRANCH OFFICE INFORMATION
This information is required only if the CA is the Designated Certified Applicator in a Branch Office other than the
licensee home office. The licensee must also register the Branch Office on the Branch Office Registration Form.
Company Name:
Telephone Number:
Street Address
Mailing address (if different from street address)
APPLICANT, EMPLOYER AND RESIDENT AGENT CERTIFICATION
I hereby certify that the information given in this application is true and correct.
Signature of Applicant:
Date:
Signature of Licensee (commercial) or Employer (noncommercial only):
Date:
Signature of Resident Agent (required if applicable):
Date:
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INSTRUCTIONS FOR COMPLETING THE CERTIFIED APPLICATOR'S CARD APPLICATION (Information Technology Services)

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Completed 19 May 2022

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