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 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 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 p roducers 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 XXXX-XX-X Requesting federal certificate based on valid federal, state or tribal certificate or license. (Attach a copy of certificate.)

Training and self-evaluation (ONLY for private applicators who do not hold a certification) 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 faithINSTRUCTIONS 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 requi red. 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 ch eck “Requesting federal certificate based on valid federal, state or tribal certificate or license”. 6a. Enter the two character state for which you hold a va lid 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 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 an d 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 appli cation with a photocopy of both sides of your existing federal, state, or tribal pesticide applicator certif icate/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 estim ate 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.