Form No. 19 - Registration Of Employee(S) Working Under The Supervision Of A Licensee Or Non-Conmmercial Certified Applicator - North Carolina Department Of Agriculture And Consumer Services
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1NORTH CAROLINA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
STRUCTURAL PEST CONTROL & PESTICIDES DIVISION
1090 MAIL SERVICE CENTER, RALEIGH, NC 27699-1090
REGISTRATION OF EMPLOYEE(S) WORKING UNDER THE SUPERVISION OF A LICENSEE
OR NON-CONMMERCIAL CERTIFIED APPLICATOR
BEFORE YOU BEGIN
: Answer questions 1-5 for each employee/applicant.
Check Yes or No and enter the required
dates. Do NOT submit this application for employees who are not eligible. Employees must be registered within 75 days of
employment.
QUESTION
ANSWER
1. Has the applicant(s) completed the
Yes
No
No
STOP
HERE: The applicant is not
introductory training workbook and 24
eligible. Do NOT submit at this time.
hours of on-the-job training in the
Introductory training is required.
applicable phases?
STOP
HERE: The applicant is not
2. Has the applicant(s) attended the
Yes
No
No
Registered Technician School or approved
Enter the training dates:
eligible. Do NOT submit at this time. The
equivalent training?
___/___/________ ___/___/_________
training must be completed before this
Attach the certificate to this form.
employee can apply.
3. To your knowledge, has the applicant(s)
Yes
No
Unknown
ever had a registered technician or certified
Enter the previous license/file numbers if available. ___________________________
applicator card issued in NC?
4. The applicant(s) will be working under
Yes
No
No
STOP
HERE: The applicant is not
your supervision. Is your license/CA card
eligible. Your license must be current and
Enter Lic. Expire Date: ___/___/______
current and active?
active.
5. Are you aware a $40.00 fee is required for EACH applicant
Yes
and the Registered Technician card expires on June 30 each year?
Total Enclosed: $___________
FEE: $40.00 Duplicate FEE $5.00
APPLICANT # 1.
Enter Full Name of Employee/Applicant
Social Security Number
Hire Date:
Date of Birth:
Height:
Weight:
Hair Color:
Eye Color:
Job Title:
Home Address:
City:
State:
Zip Code:
FEE: $40.00 Duplicate FEE $5.00
APPLICANT # 2.
Enter Full Name of Employee/Applicant
Social Security Number
Hire Date:
Date of Birth:
Height:
Weight:
Hair Color:
Eye Color:
Job Title:
Home Address:
City:
State:
Zip Code:
BUSINESS INFORMATION
(Type or Print In Ink)
Application is hereby made for Registered Technician’s Identification Card(s) for the above employee(s) working under the
supervision of:
Licensee/Certified Applicator: ______________________________________________Lic./Ca No. __________________
Company Name:
_________________________________________________________________________________________________
Company/Office Address:
_________________________________________________________________________________________________
(Street Address)
(P.O. Box)
(City)_______________________________(State)_______(ZipCode)___________Telephone No: (______) -_____________
I hereby certify that none of the employees listed above have, within 3 years of the date of this application, been convicted of, plead
guilty or nolo contendere, or forfeited bond, in any state or federal court for a felony or any violation of the N.C. Structural Pest
Control Law or to any regulation promulgated by the N.C. Structural Pest Control Committee.
In addition, I certify that the above employees have received the training prescribed by the Committee for all registered technician’s
identification card applicants as provided in G.S. 106-65.29.
Signature of licensee or certified applicator: ________________________ Date: ___________
Form No. 19 Rev (August, 2010)
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