Fill - Free fillable STRUCTURAL PEST CONTROL APPLICATION FOR APPLICATOR EXAMINATION FEE (California) PDF form

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

STRUCTURAL PEST CONTROL BOARD-LICENSING UNIT

2005 EVERGREEN STREET, STE. 1500 SACRAMENTO, CA 95815

916-561-8704 F 916-263-2469

| |

WWW.PESTBOARD.CA.GOV

APPLICATION FOR

STRUCTURAL PEST CONTROL

APPLICATOR EXAMINATION

FEE $55

(Remit by money order, cashier's, personal or certified

check payable to the Structural Pest Control Board.)

FOR BOARD USE ONLY

ATS No. ______________________

Cashiering No. _________________

Results _______________________

INSTRUCTIONS:

 Each question must be fully and truthfully answered.

 Attach sheets to this application wherever so directed or when space provided is not sufficient.

 An incomplete application will be returned to the applicant.

 A $55 Examination Fee is required.

 ALL FIELDS MUST BE TYPED OR PRINTED.

PLEASE

NOTE:

State law

requires an

applicant

complete the Live Scan/fingerprint process

for

the purpose of

conducting

criminal

history

record

checks

prior

licensure.

PLEASE PRINT OR TYPE DATE OF BIRTH

SOCIAL SECURITY NO.

_________________________

________________________

(or Individual Tax Identification Number)

1. Name of Applicant:

(First) (Middle) (Last)

2. Residence Address:

City

State

Zip

Telephone Number:

( )

Email address (optional):

3. Mailing Address:

(This address is where the Candidate’s Handbook will be mailed.)

City State Zip

4. Employed by:

(Firm name)

5. Employer’s Address:

City State Zip

Telephone Number:

(

)

43E-8 (Rev. 07/2020)

6. Are you 18 years of age or older? YES NO

. Have you ever applied for the applicator, field representative or operator’s examination? YES NO

If YES, when

. Are you presently licensed or have you previously been licensed as an applicator,

a field representative or an operator in the State of California?

YES NO

If YES, state license number(s

)

Do you have any pending disciplinary action against you in regards

to a structural pest control professional or vocational licens

YES NO

If YES, attach a detailed statemen

10. Are you now or have you ever been a partner in a company or an officer

of a corporation licensed by the Structural Pest Control Board?

YES NO

If YES, list name(s) of companies

11. Have you, or any company with which you have been affiliated, had a professional

or vocational license denied, suspended, or revoked by this or any other state?

YES NO

If YES, attach a detailed statemen

. Have you ever been convicted of any violation of any provision of t

Structural Pest Control Act?

YES NO

If YES, attach a detailed statement.

VIOLATIO

N OF THE SECURITY OF THE EXAMINATION, INCLUDING CHEATING ON AN EXAMINATION, IS A MISDEMEANOR. IF

YOU ARE

FOUND GUILTY, YOU COULD RECEIVE A FINE, A JAIL SENTENCE OR BOTH. IT IS ALSO REASON FOR

DISQUALIFICATION FROM THE EXAMINATION AND DENIAL OF A LICENSE.

IF YOU VIOLAT

E THE SECURITY OF THE EXAMINATION AND ARE FOUND GUILTY, IN ADDITION TO OTHER PENALTIES, YOU

WILL BE HEL

D LIABLE FOR ACTUAL DAMAGES CAUSED TO THE STRUCTURAL PEST CONTROL BOARD FOR UP TO $10,000 AND

THE COSTS OF LITIGATION (BUSINESS AND PROFESSIONS CODE SECTION 123).

SOME VIO

LATIONS OF EXAMINATION SECURITY ARE:



Removing examination materials from examination rooms



Copying any portion of the examination materials



Talking to any other candidate during the examination



Copying answers from another candidate



Allowing another person to copy your answers



Having books, notes, etc. during the examination



Taking the examination for someone else



Letting someone else take your examination



Memorizing questions or answers from the examination to share with others



Getting examination questions or other materials before, during or after the examination



Selling, buying, receiving any portion of a future, current or previously administered examination

The information on this application is required pursuant to Sectio

ns 8560 and following of the Business and Professions Code. All information requested

in this application is mandatory, none is voluntary. Failure to provide any of the requested information will result in the application being rejected as

incomplete. The information you furnish will be used to determine whether you do or do not meet the requirements for which you are applying. The

information you provide may be transferred to other governmental and law enforcement agencies and may be disclosed upon a Pub lic Records Act

request made pursuant to Section 6250 of the Government Code. You have a right of access to records maintained by this agency which contain personal

information about you subject to the provisions of the Information Practices Act. (§1798 et. seq of the Civil Code) The infor mation is maintained by the

Structural Pest Control Board, 2005 Evergreen Street, Suite 1500, Sacramento, CA 95815-3831; telephone 916/561-8704. The Registrar of the Board is

the Custodian of Records.

CERTIFIED TRUE STATEMENT

I have read and understand the above and I certify under penalty of perjury under the laws of the State of California to the truth and accuracy of all

statements and representations made in this application, including all statements attached hereto. I understand that falsifying information on this

application may result in the denial of this application.

Original Signature of Applicant

Date

Attach 2” x 2" photo here

IMPORTANT NOTE: REFER TO SECTION 8564.5 OF THE BUSINESS AND PROFESSIONS CODE TO ENSURE YOU

MEET THE ELIGIBILITY REQUIREMENTS FOR LICENSURE.

This application must be completed in accordance with the instructions provided on the first page of this application. Be su re you are prepared for the

examination before completing this application. Lack of preparation is not considered a valid reason for postponement, as provided in section 1941 of

the Rules and Regulations. Such request will be denied and the examination fee forfeited.

Disclosure of your social security number (SSN) or Individual Tax identification Number (ITIN) is mandatory. Section 30 of the Business and

Professions Code and Public Law 94-455 (42 USCA 405(c)(2)(C)) authorize collection of your SSN or ITIN. Your SSN or ITIN will be used

exclusively for tax enforcement purposes, for purposes of compliance with any judgment or order for family support in accordance with Family Code

Section 17520, or for verification of licensure or examination status by a licensing or examination entity which utilizes a n ational examination and where

licensure is reciprocal with the requesting state. If you fail to disclose your SSN or ITIN, your application for examination will not be processed AND

you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you.

If you have any questions regarding the application for examination, contact the Examination/Licensing Unit.

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NOTICE ON COLLECTION OF PERSONAL INFORMATION

Collection and Use of Personal Information

The Structural Pest Control Board of the Department of Consumer Affairs collects the

personal information requested on this form as authorized by Business and Professions

Code Section 8560 and the Information Practices Act. The Structural Pest Control

Board uses this information principally to identify and evaluate applicants for licensure,

issue and renew licenses, enforce licensing standards set by law and regulation, update

and maintain current licensee information, and for mailing purposes.

Mandatory Submission

Submission

of the

requested information is mandatory. The

Structural Pest Control

Board

cannot consider your application

for licensure or renewal unless you provide all of

the requested information.

Access to Personal

Information

You may review the records maintained by

the

Structural Pest Control Board

that

contain your personal information, as permitted by the

Information

Practices Act. See

below for contact information.

Possible Disclosure

of Personal Information

make every effort to protect the

personal information you provide us. The

information you

provide, however, may be disclosed in the

following circumstances:

 In response to

a Public Records Act request (Government Code Section 6250

and

following), as allowed by the Information Practices Act (Civil Code Section

1798 and

following);

 To another government agency as required by State or Federal law; or,

 In response to

a court or administrative order, a subpoena, or a search warrant.

Contact Information

For questions about this notice or access to your records, you may contact:

The

Structural Pest Control Board at 2005 Evergreen

Street, Suite

1500, Sacramento, CA

95815, by phone at (916) 561-8704, or by email at

pestboard@dca.ca.gov.

For questions about the Department’s Privacy Policy, you may contact the Department

of Consumer Affairs at 1625 North Market Boulevard, Sacramento,

CA 95834, by phone

at (800) 952-5210, or by

email at dca@dca.ca.gov.

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STRUCTURAL PEST CONTROL APPLICATION FOR APPLICATOR EXAMINATION FEE (California)

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