New York State Pesticide Agency Registration Application Page 2 of 2
6. Pesticide, Equipment, and Records Storage.
Does your agency store pesticides, application equipment, or records at a location different than box 3? ______ Yes ______ No
If YES provide the address or addresses below. Attach additional sheet if necessary.
Pesticide and/or equipment storage address: Pesticide records storage address:
7.
Decals. Any vehicle transporting pesticides or trans
porting pesticide application equipment needs pesticide identification decals. Large pieces of
motorized ride-on application equipment must also display decals. Provide the number of vehicles (including trailers and pieces of ride-on application
equipment)
used to transport pesticides and application equipment.
Number of vehicles: _____________
8. Categories of Pesticide Operation. Indicate which pesticide categories the agency operates in, check all that apply. For categories marked with
an * the agency must employ an applicator certified in that category, for all other categories the agency must employ an applicator or a technician
certified in that category.
___ 1a Agricultural Plant* ___ 5a Aquatic Vegetation Control* ___ 7c Termite*
___ 1b Agricultural Animal* ___ 5b Aquatic Insect Control* ___ 7d Lumber & Wood Products*
___ 1c Companion Animal* ___ 5c Aquatic Fish Control* ___ 7f Food Processing*
___ 1d Fumigation of Soil & Ag Commodities* ___ 5d/13 Aquatic Antifouling Paints ___ 7g Cooling Towers, Pulp & Paper Process*
___ 2 Forest Pest Control ___ 5e Sewer Line Root Control* ___ 8 Public Health Pest Control
___ 3a Ornamentals, Shade Trees & Turf ___ 6a Right-of-Way Vegetation Control ___ 9 Regulatory Pest Control
___ 3b Turf ___ 6b Right-of-Way in Place Pole Treatments ___ 10 Demonstration & Research Pest Control
___ 3c Interior Plant Maintenance ___ 7a Structural & Rodent Control* ___ 11 Aerial Pest Control*
___ 4 Seed Treatment ___ 7b Fumigation*
9. Employees that apply pesticides. List all certified commercial pesticide applicators, certified commercial pesticide technicians, commercial
pesticide apprentices or antifouling paint applicators employed by the agency. Please provide the ID number, card expiration date and certification
categories of the certified pesticide applicators and technicians. List the names of all trained Apprentices. Attach additional sheet if necessary.
Contractors or consultants cannot make or supervise pesticide applications.
Name of Applicator, Tech, or Apprentice New York Certification Number Certification Expiration Date Certification Categories
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
10. Applicant/Authorized Representative Acknowledgment.
This form must be signed by an appropriate agency official with full legal authority to sign this application on behalf of the
agency. The signature of
the applicant must be notarized. The applicant is legally accountable for the content of the application, and legally responsible for complying with all
applicable statutory and regulatory requirements of an agency registration. Applications signed by administrative assistants, secretaries, or office
managers will not be accepted.
I declare and affirm that the information provided in this application, including accompanying documents, are accurate, true, complete
and correct to
the best of my knowledge and belief. I understand that any false or misleading information in, or in connection with, this application may be cause for
denial or loss of registration, and are punishable pursuant to the applicable provisions of the New York State Penal Law. I further affirm that I have
read and understand the application, instructions, and the provisions of Article 33 of the ECL and the rules and regulations promulgated thereunder.
__________________________________ __________________________________________ ______________________________________
Print Applicant Name Official Title Applicant Signature
Sworn to before
me this day of year ____________
__________________________
____________________________________________________ _________________________________
Notary Public Signature Notary Public Stamp
(Agency Registration Application 9/2019)
