8.
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GAVIN NEWSOM, GOVERNOR
STRUCTURAL PEST CONTROL BOARD-LICENSING UNIT
2005 EVERGREEN STREET, STE. 1500 SACRAMENTO, CA 95815
P
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
to
complete the Live Scan/fingerprint process
for
the purpose of
conducting
criminal
history
record
checks
prior
to
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)
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6. Are you 18 years of age or older? YES NO
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. Have you ever applied for the applicator, field representative or operator’s examination? YES NO
If YES, when
?
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. 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
)
9
.
Do you have any pending disciplinary action against you in regards
to a structural pest control professional or vocational licens
e?
YES NO
If YES, attach a detailed statemen
t.
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
t.
12
. Have you ever been convicted of any violation of any provision of t
he
Structural Pest Control Act?
YES NO
If YES, attach a detailed statement.
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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
We
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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