Please read instructions before completing form. Form Approved. OMB Control No. 2070-0029. 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 COUNTY OFFICE USE

( )

– EMAIL ADDRESS (optional)

2. BIRTH DATE: M M – D D – Y Y 3. FEDERAL APPLICATOR ID # (if renewal):

4. CERTIFICATION TYPE:

5. APPLICATOR TYPE:
6. CERTIFICATION METHOD:

a.

State (if applicable) : Applicator Number:

Expiration Date: M M - DD - YY Applicator Category/Categories for which Certificate/License was Received (enter category code(s)):
b. By signing this application below and submitting to U.S. EPA, I hereby attest to the fact that: 1. I have personally completed the required training. 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 b een, please check this box and attach an explanation.

SIGNATURE: DATE SIGNED: (FOR OFFICE USE:) REC: APP: INIT: SENT:

EPA Form 8500-17 Requesting federal certificate based on valid federal, state or tribal certificate or license. (Attach a copy of certificate.)

Completion of training (ONLY for private applicators who do not have a valid federal, state or tribal certificate or license) Commercial Applicator Private Applicator Replacement (Lost Card) Initial Certificate Renewal/Recertification

A false statement in this certification may be grounds for denial of certification and may be punishable by fine or imprisonmen t (U.S. Code, Title 18, Section 1001). I certify that all the statements that I have made on this form are true, complete and cor rect to the best of my knowledge and belief, and are made in good faith.

### 1 INSTRUCTIONS FOR COMPLETING EPA FORM 8500-17 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. The phone number and address listed should be your business phone number and business address, if applicable. The phone
num ber should be one at which you can be reached during business hours. For commercial applicators, both the address and phone number will be posted to EPA's website. 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”. If contact information submitted on a previous form is erroneous or outdated, please use the “Replacement (Lost Card)” option. 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. A ttach a photocopy of both sides of your current and valid federal, state or tribal certification or license

. The underlying certificate needs to come from a state or tribe that shares a contiguous boundary with the area of Indian country in which you intend to apply RUPs. 6b. If you do not hold a valid federal, state or tribal applicator certificate and you are applying to be a private applicator, you may be certified after submitting documentation of completion of the on-line training course provided by EPA. A false statement in this certification, including regarding the completion of training, may be grounds for denial of certification and may be punishable by fine or imprisonment (U.S. Code, Title 18, Section 1001). Include documentation of completion of the required training course(s). To apply for recertification, complete one of the options described above during the 12 months preceding the expiration of your current certificate. 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 the appropriate Regional office (see addresses on page 2). To determine the appropriate Regional office, see http://www2.epa.gov/aboutepa#pane-4
.

### 2

Addresses for Submitting Form Note: To determine the appropriate Regional office, see http://www2.epa.gov/aboutepa#pane-4
. Region Address Region Address

1 Federal Plan Coordinator Toxics and Pesticide Unit Pesticides Program (OES05

- 4) U.S. EPA

- New England, Region 1 5 Post Office Sq, Suite 100 Boston, MA 02109

- 3912 6 U.S. Environmental Protection Agency 1445 Ross Avenue, Suite 1200 Pesticides Section (6PD

- P) Dallas, Texas 75202

- 2722

2 U.S. Environmental Protection Agency, Region 2 Pesticides Team Attn: Pesticide Certification Training Coordinator 2890 Woodbridge Avenue MS

- 500 Edison, New Jersey 08837 7 Pesticide Applicator Certification Coordinator U.S. Environ mental Protection Agency

- Region 7 WWPD/TOPE/PEST 901 N. 5th St Kansas City, KS 66101

3 No Federally Recognized Tribes 8 US EPA, Region 8 Attn: Region 8 Certification 1595 Wynkoop St, 8P

- P3T Denver, CO 80202

4 Federal Tribal Plan Coordinator USEPA Region 4

- Pesticides Section 61 Forsyth Street SW SNAFC

- 12th Floor Atlanta, GA 30303 9 Federal Plan Coordinator Pesticides Office (CED

- 5) U.S. EPA Region IX 75 Hawthorne St. San Francisco, CA 94105

- 3901

5 U.S. Environmental Protection Agency ATTN: Pesticide Applicator Plan Pesticide Program Section 77 W. Jackson Blvd. LC

- 8J Chicago, IL 60604 10 Federal Pesticide Applicator Certification Program Pesticides & Toxics Unit US EPA, Region 10 1200 Sixth Ave, Ste. 900, OCE

- 084 Seattle, WA 98101

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 8500-17) 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. Privacy Act Statement: Title 7 United States Code, section 136i(a)(1) authorizes the collection of this information. The primary use of this information is to identify persons certified by EPA under the Agency’s federal certification plan which administers and oversees certification of applicators of restricted use pesticides. Disclosures of this information may be made pursuant to published routine uses, including to appropriate agencies for law enforcement purposes and to an EPA website for information purposes. Providing the requested information is voluntary, but failing to do so may result in EPA’s inability to approve your request to become, or maintain your status as, a certified applicator of restricted use pesticides. For a full description of this system notice, including routine uses, see EPA-59 [77 FR 2060; January 12, 2012].