Fillable STRUCTURAL PEST CONTROL APPLICATION FOR FIELD REPRESENTATIVE EXAMINATION (California)

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STRUCTURAL PEST CONTROL APPLICATION FOR FIELD REPRESENTATIVE EXAMINATION (California)

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The STRUCTURAL PEST CONTROL APPLICATION FOR FIELD REPRESENTATIVE EXAMINATION (California) form is 3 pages long and contains:

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  • 3 check-boxes
  • 43 other fields

Country of origin: US
File type: PDF

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1
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
FIELD REPRESENTATIVE EXAMINATION
FEE $50 PER BRANCH
(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 $50 Examination Fee per branch 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.
DATE OF BIRTH _________________________
SOCIAL SECURITY NO. ________________________
(or Individual Tax Identification Number)
1. Check branch(es) in which you are applying for examination:
Branch 1 - The practice relating to the control of household and wood-destroying pests or
organisms by fumigation with poisonous or lethal gases.
Branch 2 - The practice relating to the control of household pests excluding fumigation with
poisonous or lethal gases.
Branch 3 - The practice relating to the control of wood-destroying pests or organisms by the use of
insecticides or structural repairs and corrections, excluding fumigation with poisonous or lethal gases.
2. Name of Applicant:
(First) (Middle) (Last)
3. Residence Address:
City State Zip
Telephone Number:
(
)
Email address:
4. Mailing Address:
(This address is where the Candidate’s Handbook will be mailed.)
City State Zip
5. Employed by:
(Firm name)
6. Employer’s Address:
8.
City State Zip
Telephone Number:
(
)
43E-6 (Rev. 07/2020)
2
7. Are you 18 years of age or older?
YES NO
8. Have you ever applied for the field representative or operator’s examination? YES NO
If YES, when?
9. 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)
10. Do you have any pending disciplinary action against you in regards
to a structural pest control professional or vocational license?
YES NO
If YES, attach a detailed statement.
11. 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
12. 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 statement.
13. Have you ever been convicted of any violation of any provision of the Structural Pest Control Act?
YES NO
If YES, attach a detailed statement.
14. Are you now or have you ever been licensed to do structural pest control
in another State?
YES NO
If YES, you will be required to submit a certified license history from that State’s Licensing Agency
as well as a copy of that State’s Rules and Regulations before the issuance of a license.
3
VIOLATION 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
DISQUALIF
ICATION FROM THE EXAMINATION AND DENIAL OF A LICENSE.
IF YOU VIOLATE 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 COST S OF LITIGATION (BUSINESS AND PROFESSIONS CODE SECTION 123).
SOME VIOLATIONS 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 Sections 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 Public 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 information 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 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 sure 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 national 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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4
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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STRUCTURAL PEST CONTROL APPLICATION FOR FIELD REPRESENTATIVE EXAMINATION (California)

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Completed 20 July 2021

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