Fillable PESTICIDE BUSINESS REGISTRATION APPLICATION New York State Department (New York State)

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PESTICIDE BUSINESS REGISTRATION APPLICATION New York State Department (New York State)

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New York State Department of Environmental Conservation
Division of Materials Management
Bureau of Pest Management
625 Broadway 9
th
Floor, Albany, New York 12233-7254
Phone: (518) 402-8748
Website: www.dec.ny.gov
For NYSDEC Official Use Only
Registration Number __________
_
Region _____
_
Expiration Date __________
_
Number of Decals Issued ____________ From _____________ To ______________
_
PESTICIDE BUSINESS REGISTRATION APPLICATION
BUSINESSES APPLYING PESTICIDES FOR-HIRE
Each business location offering, advertising or providing the services of commercial application of pesticides either entirely or as part of the business
must register with the Department of Environmental Conservation. Non fee exempt agencies (per 6NYCRR Part 325.23) must use this form.
Businesses must register each location with a separate application and pay the registration fee for each place of business. Businesses offering,
advertising or providing the services of commercial application of pesticides under more than one business name must register and pay the registration
fee for each business name at each place of business. However, businesses may list more than one assumed name (DBA or AKA) on a single
registration application.
The registration expiration date is determined by the DEC Region and/or county in which a business is located. Fees will not be prorated for any part of a
registration period. The registration period is for three years. To determine your Region, see http://www.dec.ny.gov/about/50230.html
The expirations dates are:
Region 1 (Nassau): October 31; Region 1 (Suffolk): December 31; Region 2: February 28; Region 3: April 30; Region 4: June 30; Region 5: June
30; Region 6: June 30; Region 7: July 31; Region 8: August 31; Region 9: September 30; Out of State: June 30
Renewal applications must be mailed at least 30 days before your registration expires to avoid a lapse in registration.
These directions should be followed carefully in completing the pesticide business registration application. Fill in all required information.
Your application will be returned if it is incomplete or not completed correctly. Please type or print legibly.
Payment Instructions: The registration/renewal fee is $900.00. Do not submit your payment when you submit your application. After your
application is reviewed and accepted you will be sent an invoice. Once you receive your invoice you will be able to pay online with a credit card, debit
card, or e-check, or you can pay by mail with a check or money order. After your payment is received your registration will be issued.
1. _____ New Or _____ Renewal If a renewal, enter your current registration number: ______________
2. Business Name. Provide the complete legal name of business and all doing business as (DBA) or assumed names. These are the only business
names that can be used on websites or advertisements and on contracts for pesticide application services. For the legal name provide the Corporate,
LLC, or Partnership name, if the business is a Sole Proprietorship provide the name of the owner.
Legal Name __________________________________________________________________________________________________________
DBA Names (If none leave blank) ___________________________________________________________
_
_
___________________________
_
3. Business Address. Provide the physical address of the business and mailing address if it different than the physical address. Include any suite,
unit, or apartment numbers. A PO Box, UPS Store, or other mail box service cannot be used as the physical address.
Physical Address:
Street Address ______________________________________________________________________________________________________
City ____________________________________ State __________ Zip Code ____________________ County ________________________
Mailing Address:
(If it is the same as the physical address leave blank)
PO Box or Street Address _____________________________________________________________________________________________
City ____________________________________ State __________ Zip Code ____________________
4.
Main Business Phone Number. (________) ________ - __________
Page 1 of 3
New York State Pesticide Business Registration Application Page 2 of 3
5. Pesticide, Equipment, and Records Storage.
Does your business 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:
6. Select the type of ownership for this business.
____ Sole Proprietor ____ Partnership ____ Corporation or S-Corp ____ LLC
____ Other ________________________________
7. Business Owners and Corporate Officers. All businesses must provide the names of all business owners, corporations or LLC’s must also
provide the names of corporate officers or LLC managers. Attach additional sheet if necessary.
Owners Corporate Officers
Name Ownership Percentage Name Position / Job Title
___________________________________ ________________ __
_________________________________ _________________
___________________________________ ________________ ___________________________________ _________________
___________________________________ ________________ ___________________________________ _________________
_
_________________________________
_
_______________
_
_________________________________
_
_
______________
_
_
8. Decals. Any vehicle transporting pesticides or transporting 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: _____________
9. Categories of Pesticide Operation. Indicate which pesticide categories the business operates in, check all that apply. For categories marked
with an * the business must employ an applicator certified in that category, for all other categories the business 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*
10. Employees (including owners) that apply pesticides. List all certified commercial pesticide applicators, certified commercial pesticide
technicians, commercial pesticide apprentices or antifouling paint applicators employed by the business. 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
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
New York State Pesticide Business Registration
Application Page 3 of 3
11. Liability Insurance. All businesses must provide a certificate of liability insurance. Do not send vehicle or workers compensation insurance.
Binders or policy declarations are not acceptable. The Department will accept insurance coverage afforded by: 1) insurers classified by the New
York State Department of Financial Services (NYDFS) as licensed; 2) insurers listed as an ELANY Eligible E&S insurers.
! Minimum commercial general liability insurance requirements are $1,000,000 each occurrence or $1,000,000 per incident bodily injury.
! The business name & address on the insurance certificate must be exactly the same as on this application form.
! NYS DEC Pesticide Reporting and Certification Section, 625 Broadway, Albany, NY 12233-7254 must be listed as the certificate holder.
! Insurance policies that expire in less than 30 days will not be accepted.
______ I have attached the certificate of insurance.
12. Contact Information. Who should the DEC contact if we have questions about this application?
Name ____________________________________________ Phone Number (________) ________ - __________Extension ______________
Email Address ________________________________________________________________
13. Applicant/Authorized Representative Acknowledgment
This form must be signed by an appropriate
business official with full legal authority to sign this application on behalf of the applicant. The signature
of the applicant must be notarized. If the business is a sole proprietor the form must be signed by business owner, if the business is a partnership
the form must be signed by a business partner, if the business is a corporation or LLC the form can be signed by an owner, corporate officer, director,
manager, member, partner, etc. Applications signed by administrative assistants, secretaries, or office managers will not be accepted. The applicant
is legally accountable for the content of the application, and legally responsible for complying with all applicable statutory and regulatory requirements
of a business registration.
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
Before mailing this application have you
Comple
ted all 13 boxes? Incomplete applications will be rejected.
Included the names of ALL employees, including apprentices, who make pesticide applications in box 10?
Included a certificate of liability insurance?
After your application is reviewed and accepted by the Pesticide Reporting and Certification Section an invoice will be sent to you by
the NYSDEC Revenue Accounting Unit. You will be able to pay online with a credit card, debit card, or e-check, or you can pay by mail
with a check or money order. If you do not pay the invoice within 30 days, you will be required to submit a new application. Your
registration certificate will be issued after full payment is received.
Mail this original completed application and insurance certificate to:
NYSDEC Pesticide Reporting and Certification Section
625 Broadway 9
th
Floor
Albany, NY 12233-7254
Ph
otocopies or scanned applications will not be accepted.
If you have any questions, please call 518-402-8748 or email pestmgt@dec.ny.gov
(Business Registration Application 9/2019)
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PESTICIDE BUSINESS REGISTRATION APPLICATION New York State Department (New York State)

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Completed 23 August 2020

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