Structural Pest Control Business / Qualifying Manager Registration Form Page 2

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RIVERSIDE COUNTY AGRICULTURAL COMMISSIONER
STRUCTURAL PEST CONTROL BUSINESS / QUALIFYING MANAGER REGISTRATION
BRANCH 2 & 3
ADDITIONAL LOCATIONS
Company Name: _______________________________
For Year: 2016
1) Branch Office (list all) performing work in:
Riverside County
_________________________________
Branch Address:
BR License No. __________
_________________________________
_________
Zip
□
□
Telephone: (
) __________ Fax: (
) __________ Working in:
Branch 2 &/or
Branch 3
SUPERVISION: Qualifying Manager – QM and Branch Supervisor (Responsible Person) - BS
QM:
Lic:____________ Exp: ________ Branch 2 / Branch 3
(Print Name)
QM:
Lic: ____________ Exp: ________ Branch 2 / Branch 3
(Print Name)
BS: __________________________________ Lic: ____________ Exp: _________ Branch 2 / Branch 3
(Print Name)
2) Branch Office:
_________________________________
Branch Address:
BR License No. __________
_________________________________
_________
Zip
□
□
Telephone: (
) __________ Fax: (
) __________ Working in:
Branch 2 &/or
Branch 3
SUPERVISION: Qualifying Manager – QM and Branch Supervisor (Responsible Person) - BS
QM:
Lic:_____________Exp: ________ Branch 2 / Branch 3
(Print Name)
QM:
Lic:_____________ Exp: ________ Branch 2 / Branch 3
(Print Name)
BS: __________________________________ Lic:_____________ Exp: ________ Branch 2 / Branch 3
(Print Name)
3) Branch Office:
_________________________________
Branch Address:
BR License No. __________
_________________________________
_________
Zip
□
□
Telephone: (
) __________ Fax: (
) __________ Working in:
Branch 2 &/or
Branch 3
SUPERVISION: Qualifying Manager – QM and Branch Supervisor (Responsible Person) - BS
QM:
Lic:____________ Exp: ________ Branch 2 / Branch 3
(Print Name)
QM:
Lic:____________ Exp: ________ Branch 2 / Branch 3
(Print Name)
BS: __________________________________ Lic:____________ Exp: ________ Branch 2 / Branch 3
Agricultural Commissioner’s Signature _____________________________ Date:___________
Est. 11/2007
Page 2 of _____

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