ࡱ>  bjbjWW .55x2228j|T2Q :::::|~~~~~~$="$ill"::2 ::||:@YcLh! 0Q %0%%L6,<j.rQ % : Application for Commercial Pesticide Applicator Exams and License Please complete an application for each candidate by printing or typing the requested information and checking all the appropriate boxes. Mail the completed application to: Board of Pesticides Control, 28 State House Station, Augusta, ME 04333-0028 This form is for applicants wishing to pre-pay the license fee at the same time as paying the exam fees. Licensee understands that if they do not pass the required exams within 12 months they will forfeit the license fees. NameSocial Security #Home Mailing AddressHome Phone #Cell Phone #City State ZipBusiness Phone #Company/AgencyE-mail AddressBusiness Mailing AddressCity State ZipFederal ID # RequiredSignature of LicenseeTitleSignature of Owner/ManagerTitle Type of Applicator Industrial/BusinessGovernmental( Custom Applicator (For Hire)( Federal( Not For Hire (Apply to Company Areas Only)( State( University( Municipal Exams Desired:( Master Oral( 3A-Outdoor Ornamentals( 7C1-Disinfectant & Biocide( 8B-Public Health/Other**( Master Regulation( 3B-Turf( 7C2-Swimming Pool & Spa( 9-Regulatory**( Core( 3C-Indoor Ornamentals( 7C3-Mold Remed/Water Dam*( 10-Demo & Research***( 1A-Agricultural Animal( 4-Seed Treatment( 7D1-Pressure Treating( 11-Aerial***( 1B-Agricultural Plant( 5A-Aquatic( 7D2-Sapstain/Bluestain( 1B1-Ltd. Comm. Blueberry( 5B-Sewer Root Control( 7D3-Remedial Treatment( 1B2-Agricultural Chemigation( 6A- R-O-W Vegetation Mgmt( 7D4-General Wood Treatment( 1B3-Agricultural Fumigation( 6B-Ind/Comm/Muni Veg Mgmt( 7E-Biting Fly & Tick( 1B4-Post Harvest Treatment( 7A-Structural General( 7F-Termites( 2-Forest( 7B-Structural Fumigation( 8A-Public Health/Biting Fly** * These categories need only take one exam the core exam is not required. ** These categories are only for government officials. *** These categories are not stand-alone. Applicants must also apply for categories they plan to make applications under. Exam FeesExam fees are $10.00 per core or category exam. The Master oral and regulation exams are $50.00 for the two combined. Failure to pass any exam requires a new application and fee to be submitted. Exam fees are not refundable. Government officials are exempt from all fees. Number of core and/or category exams checked x $10.00 = Master Exams = $__________ $ 50.00 Total Exam Fee $___________  All Applicants must complete Sections 1-3 Section 1 Application for: (Note: No fees for governmental applicators) % Initial License $70.00 fee % Replacement License $5.00 fee % License Renewal $70.00 fee % Updated License (add/category/upgrade) $5.00 fee Total License Fee $____________ Section 2 Qualification for: (Note: Does not apply to Household Pet, Antifouling Paint, or Post Harvest Treatment applicators) % Operator % Master Section 3 Type of License: % Governmental % Custom Applicator for Hire % Custom Applicator Nor for Hire Company/Agency owner, manager or master must complete Section 4 Section 4a Annual Summary Reports Section 4b Insurance Affidavit % Have been submitted % Affadavit enclosed % Are enclosed % Previously submitted % None performed % Not required (not for hire)  For hire companies must complete Section 5 Section 5a % Only apply pesticides on or within a premises which is company owned or leased (This type of company need not apply for a firm license) % Sole Proprietor with NO employees that apply pesticides (This type of company need not apply for a firm license) % Sole Proprietor WITH employees that apply pesticides % Incorporated % Partnership % LLC (This type of company need not apply for a firm license) Fees Enclosed Please make checks payable to Treasurer, State of fb88 (from page 1) Total Exam Fee $____________ (from top of page 2) Total License Fee $____________ Total Enclosed $____________ Licensee understands that if they do not pass the required exams within 12 months they will forfeit the license fees. Exam ScheduleExam appointments are sent to all applicants after receipt of a complete application and appropriate fee. Please allow 7 10 business days to receive confirmation of your appointment. Most exams are offered weekly on Wednesday mornings. Master exam candidates may be scheduled on other days. Master candidates should indicate their time and date preferences below. We will do our best to accommodate your needs. ( Prefer Morning ( Prefer Afternoon Dates preferred: ________________________________________ Dates to avoid: _________________________________________ If you are unable to appear at the scheduled time, please call (207)-287-2731 to request a new appointment. The Boards regulations require at least a 24 hour notice if you cannot make your appointment. Less than 24 hour notice or canceling two times in a row results in loss of the exam fees and an additional $15.00 re-application fee above and beyond the regular exam fees. Core and Category exam study materials are available from The University of fb88 Pest Management Office at 1-800-287-0279. The Master regulation exam study guide is mailed from the BPC office upon receipt of your application. Master Level Education/Experience HistoryPlease list your current or expected pesticide management responsibilities.Please describe any previous pesticide management employment. Please list any post secondary school programs completed.  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