Fillable PesticideCertificationExamRegistrationForm City Haveyoueverbeenconvictedofafelony? NYSDECPesticideCertificationNo.(ifapplicable)EMail(Optional) SECTION1 State DaytimePhone ZipCode (New York State)

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PesticideCertificationExamRegistrationForm City Haveyoueverbeenconvictedofafelony? NYSDECPesticideCertificationNo.(ifapplicable)EMail(Optional) SECTION1 State DaytimePhone ZipCode (New York State)

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LastName(asitappearsonyourNYSDMVID) MI DateofBirth

//

Apt.No.

State DaytimePhone

Yes_____No_____(Ifyes,seetheinstructions,page1)

__Firsttimeexam(Core&Category$100)

____Retest($100)

____Re‐certification($100)

Private:

__21

__22 Fruit

__23

__24 Greenhouse&Florist

__25 Nursery,Ornamentals&Turf

__31

__41 AquaticPest

Commercial:

__Core

__1A

__1B

__1C

__1D

__2

__3A

__3B

__3C

__4

__5A

__5B

__5C

__5D

__5E

__6A

__6B

__7A

__7B

__7C

__7D

__7F

__7G

__8

__9

__10

__11

__12

__13

Madepayableto:NYSDEC

Vegetable

Ornamental&Turf

AquaticVegetation

AgriculturalAnimal

InteriorPlantMaintenance

PublicHealth

Demonstration&Research

AquaticAnti‐foulingPaintApplicato

ExamSession:EntertheLocation,DateandTimefortheexamyouwishtoattend.(seeinstructions,page2)

__Core

Field&Forage

Rights‐of‐WayVegetationControl

AquaticInsect

AquaticAnti‐FoulingPaint

Rights‐of‐WayInPlacePoleTreatment

AquaticFishControl

SewerLineRootControl

PesticideCertificationExamRegistrationForm

ExamOptions:(Seeinstructions,page1)

MailingAddress(NumberandstreetorPOBox)

City

NYSDECPesticideCertificationNo.(ifapplicable)E‐Mail(Optional)

Completetheinformationbelowandreturnatleast10dayspriortoyourscheduledexamdate.Forhelpwithyourapplication

visitwww.dec.ny.gov/docs/materials_minerals_pdf/examreginst.pdf

forcompleteinstructions.

Haveyoueverbeenconvictedofafelony?

Mailcompleteapplication,examfee(payabletoNYSDEC)andPROOFOFELIGIBILITYatleast10dayspriortothescheduled

examdatetotheRegionaloffice

chosenfortesting.Ifyouhaveanyadditionalquestionsorconcernsregardingthisform,

pleasecontacttheRegionalofficeforassistance.

FirstName

()

ZipCode

SECTION2SECTION3

AgriculturalPlant AgriculturalAnimal

SECTION1

CompanionAnimal

ChoosetheCoreand/orCategoryexamsyouwishtotake.(Seeinstructions,page1)

___AdditionalCategory($100percategory)

ExamLocation:

Examschedulefoundat:www.dec.ny.gov/nyspad/orbycontactingyourRegionalDECoffice.

Turf

Forest

SeedTreatment

FumigationofSoil&AgCommodities

2ndChoice

ExamDate/Time(s):1stChoice

Sales

Fumigation

Lumber&WoodProducts

CoolingTowers,Pulp&Paper

Regulatory

AerialPilot

Structural&Rodent

Termite

FoodProcessing

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PesticideCertificationExamRegistrationForm City Haveyoueverbeenconvictedofafelony NYSDECPesticideCertificationNo.(ifapplicable)EMail(Optional) SECTION1 State DaytimePhone ZipCode (New York State)

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Completed 18 November 2020

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