8500-17-tbd Request for Pesticide Applicator Certification in Indian

Please read instructions before completing form.

Form Approved. OMB Control No. xxxx-xxxx. Approval Expires xx-xx-xxxx

United States Environmental Protection Agency
Washington, D.C. 20460
Request for Pesticide Applicator Certification in Indian Country
LAST NAME (+ Jr, Sr, II, III etc.)

FIRST NAME

MI

MAILING ADDRESS

CITY

STATE

ZIP
–

AREA CODE

TELEPHONE

OFFICE USE

–

)

(

COUNTY

EMAIL ADDRESS (optional)

2. BIRTH DATE:

–
M

M

–
D

D

3. FEDERAL APPLICATOR ID # (if renewal):
Y

Y

4. CERTIFICATION TYPE:

Initial Certificate

Renewal/Recertification

5. APPLICATOR TYPE:

Commercial Applicator

Replacement (Lost Card)

Private Applicator

6. CERTIFICATION METHOD:
a.

Requesting federal certificate based on valid federal, state or tribal certificate or license. (Attach a copy of certificate.)

State (if applicable):

Applicator Number:

Expiration Date:
M

M

-

D

D

-

Y

Y

Applicator Category/Categories for which Certificate/License was Received (enter category code(s)):
b.

Training and self-evaluation (ONLY for private applicators who do not hold a certification)
By signing this application below and submitting to U.S. EPA, I hereby attest to the fact that:
1.

I have physically attended an EPA-approved training course and personally completed the self-study evaluation.

2.

I understand and can apply the information therein.

3.

I understand the significance of labeling and understand my legal responsibilities for the use of pesticides in accordance with label instructions and warnings;

4.

and; I intend to purchase and use Restricted Use pesticides only for production of an agricultural commodity on property owned or rented by myself or my
employer or to other property if the application is made without compensation other than trading of personal services between producers of agricultural
commodities.

7. PLEASE SIGN HERE
I attest my certification has not been suspended or revoked in the last 4 years by any state, tribe, or territory. If it has been, please
check this box and attach an explanation.
A false statement in this certification may be grounds for denial of certification and may be punishable by fine or imprisonment
(U.S. Code, Title 18, Section 1001). I certify that all the statements that I have made on this form are true, complete and correct
to the best of my knowledge and belief, and are made in good faith

SIGNATURE:

DATE SIGNED:

(FOR OFFICE USE:)
REC:

EPA Form XXXX-XX-X

APP:

INIT:

SENT:

INSTRUCTIONS FOR COMPLETING EPA FORM xxxx-xx-x
PAPERWORK REDUCTION ACT NOTICE
This form is to be used to request certification to purchase and apply Restricted Use Pesticides in Indian
Country from the U.S. Environmental Protection Agency.
1. Fill out all of the information. An email address is requested but is not required. Phone number listed
should be one at which you can be reached during business hours.
2. Enter your birth date using the numerical month-month-date-date-year-year format.
3. Enter your EPA Federal Applicator Identification number if this is a renewal or request for a
replacement card.
4. Certificate Type: Check appropriate box. If this is your first application for a pesticide applicator
certification in Indian Country, check “Initial Certificate”.
5. Applicator Type: Check “Private Applicator” ONLY if you will be or are applying pesticides for
production of an agricultural commodity on property owned or rented by you or your employer. All other
applicators check “Commercial Applicator”. There is no “noncommercial” or “public” federal applicator
type.
6. Certification Method: In most cases you will check “Requesting federal certificate based on valid
federal, state or tribal certificate or license”.
6a. Enter the two character state for which you hold a valid certificate/license, if applicable, the applicator
number for your existing certificate, and expiration date. Enter the code for the category or categories for
which you are currently certified/licensed. Attach a photocopy of both sides of your federal, state or
tribal certification or license.
6b. If you do not hold a valid federal, state or tribal applicator certificate and you are a private applicator,
you may be certified after physically attending and completing an EPA-approved training course and
completing the self-study evaluation. Include documentation of completion of the required

training course(s) and attach the completed self-study evaluation.
7. Sign and date the application and mail the application with a photocopy of both sides of your existing
federal, state, or tribal pesticide applicator certificate/license (if you are requesting certification based on a
federal, state, or tribal certification) to:
[Need addresses for each Region]
Paperwork Reduction Act Notice: The public reporting burden for respondents completing this form is
estimated to average about 10 minutes per response. Send comments (referencing OMB Control Number
2070-0029 and EPA Form 2070-xx-x) about the burden estimate or any other aspect of this collection of
information, including suggestions for reducing the burden to: Director, Collection Strategies Division
(2822T), U.S. Environmental Protection Agency, 1200 Pennsylvania Ave., N.W., Washington, D.C.
20460. Do not send your completed application form to this address.