Please read instructions before completing form. Form Approved. OMB Control No. 2070-0029. Approval Expires 02-28-2015

United States

Environmental Protection

Agency

 US EPA Region IX

San Francisco, CA 94105

Request for Pesticide Applicator Certification in Navajo Indian Country

LAST NAME (+ Jr, Sr, II, III etc.) FIRST NAME MI

MAILING ADDRESS

CITY STATE ZIP + 4

–

AREA CODE TELEPHONE COUNTY OFFICE USE

 () –

EMAIL ADDRESS (optional)

2. BIRTH DATE: 3. FEDERAL APPLICATOR ID # (if renewal): R 9

4. CERTIFICATION TYPE: 9 Initial Certificate 9 Renewal/Recertification 9 Replacement (Lost Card)

5. APPLICATOR TYPE: 9 Commercial Applicator 9 Private Applicator

6. CERTIFICATION METHOD:

 a. 9 Requesting federal certificate based on valid state certificate or license. (Attach a copy of state certificate.)

 State: State Applicator Number:

Expiration Date:

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

 

 b. 9 Self-study (ONLY for private applicators who do not hold state certification)

By signing this application below and submitting to U.S. EPA, I hereby attest to the fact that:

 1. I have personally completed the EPA “Private Applicator Certification and Recertification Home Study Course Questionnaire.”

 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;

and

 4. 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

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:

 

 

APP: INIT: SENT:

EPA Form 8500-17-N
INSTRUCTIONS FOR COMPLETING EPA FORM 8500­17­N 

AND PAPERWORK REDUCTION ACT NOTICE

This form is to be used to request certification to purchase and apply Restricted Use Pesticides in

Navajo Indian Country from the U.S. Environmental Protection Agency Region IX. 

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 month­month­date­date­year­year format.

3. Enter your EPA Region 9 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 to Region IX for a pesticide applicator

certification in Navajo 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 

state certificate or license”.

6a. Enter the two character abbreviation for the state in which you hold a valid certificate/license, the 

state applicator number, and the expiration date. Enter the code for the category or categories for

which you are certified/licensed by the state using the codes listed on the back of this instruction 

sheet. Use the code for the category that is an exact match to the category listed on your

certificate/license. Attach a photocopy of both sides of your state certification or license.

6b. If you do not hold a valid state applicator certificate and you are a private applicator, you may be

certified after completing the “Private Applicator Certification and Recertification Home Study 

Course” and related Questionnaire.

7. Sign and date the application and mail the application with a photocopy of both sides of your state 

pesticide applicator certificate/license (if you are requesting certification based on state certification),

and a passport or digital photograph of yourself to:

Federal Plan Coordinator

Pesticides Office (CED­5)

U.S. EPA Region IX 

75 Hawthorne St.

San Francisco, CA 94105­3901

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 2070­0029 and EPA Form 8500­17­N) 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.
INSTRUCTIONS FOR COMPLETING FORM 8500­17­N (CONTINUED)

Codes for Applicator Categories (6a.)

Category  Code Category  Code

Agricultural Pest Control 1 Aquatic Pest Control 5

Agricultural Pest Control­Plant 1i Right­of­Way Pest Control 6

Agricultural Pest Control­Animal 1ii Industrial, Institutional, Structural and Health Related Pest

Control

7

Forest Pest Control 2 Public Health Pest Control 8

Ornamental and Turf Pest Control 3 Regulatory Pest Control 9

Seed Treatment 4 Demonstration & Research Pest Control 10

Arizona Department of Agriculture Specific Categories

Category  Code

Right­of­Way pest control ­ Agriculture 6a

Regulatory pest control (Government ): M­44 9a

Regulatory pest control (Government ): Rodent 9c 

Fumigation – Agriculture (Private applicator)  16

Arizona Structural Pest Control specific categories

Category Code

General Pest & Public Health B1

Control of Wood Destroying Insects  B2

Right of Way and Weed Control B3

Fumigation B4

Turf & Ornamental Horticulture B5

Fungi Inspection B7

Wood Destroying Insect Inspection B8

Aquatic Pest Control B9

Utah specific categories

Category Code

Aquatic­Surface Water  5a

Aquatic­Sewer Root Control 5b

Structural & Health­Related 7

Regulatory  9

Aerial Application 11

Vertebrate Animal 12

Fumigation/Stored Commodities  13

Wood­Preservation 14

Wood Destroying Organisms  15