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Florida Department of Agriculture and Consumer Services

Remit Fee Online at:

Division of Agricultural Environmental Services

- or -

APPLICATION FOR PEST CONTROL

Check or Money Order Payable to

FDACS:

EMPLOYEE-IDENTIFICATION CARD

FDACS

Revenue Processing Section

ADAM H. PUTNAM

Rule 5E-14.142, F.A.C.

P.O. Box 6710

COMMISSIONER

Telephone: (850) 617-7997

Tallahassee, FL 32314-671

OFFICE USE ONLY – DO NOT FILL IN

JE#

_____________ JB#

____________________

Issue Date:________________

IMPORTANT DIRECTIONS -- INCOMPLETE APPLICATIONS WILL BE RETURNED --

This application must be legible and completely filled out. Copy this form as needed, but you must submit

original signatures and the following:

(1) A CURRENT, clearly recognizable, full-faced head and shoulders photograph.

(2) A check or money order in the amount of $10.00 for each ID card made payable to “DACS”.

ATTACH RECENT

(3) A “Special Training to Perform Wood-Destroying Organism Inspections” affidavit (Form DACS-13642) MUST

ACCOMPANY this application for applicants trained to perform Wood-Destroying Organism inspections

1 1/2 x 1 1/2 INCH

and/or provide termite treatment(s) or re-inspection(s) for contractual purposes.

CLEAR, FULL-FACE

(4) A NEW applicant must submit his/her date of birth and a 4 digit Personal Identification Number (PIN) of

PHOTO HERE

His/Her choice. This combination creates a unique identifier for each person that cannot be changed. THE

EVEN IF ALREADY

APPLICANT IS RESPONSIBLE FOR REMEMBERING HIS/HER PIN NUMBER.

ON FILE

DO NOT STAPLE

_____ ID card application submitted AT THE TIME OF business license issuance – 002241 ($10)

_____ ID card application submitted with a BUSINESS LICENSE CHANGE – 001371 ($10)

(Change of Address, Change of Name or Change of Owner)

_____ ID card application submitted DURING the valid business license period – 002251 ($10)

Please issue a Pest Control Identification Card to the employee-applicant named below in accordance with Chapter 482.091, F.S., and Rule 5E-14, F.A.C.

Per Chapter 482.091(1)(b), F.S., the licensee and the certified operator in charge are jointly responsible for obtaining an identification card for

employees within 30 days of employment. The postmark date of this application will be used to document and verify the employee’s work experience

for exam purposes.

: ___________________________________________________________________JB Number: _____________________

NAME OF BUSINESS

________________________________________________________________________________________________

BUSINESS LOCATION:

(Street)

(City)

(Zip code)

_______________________________________________________________________________________

COMPLETE NAME OF EMPLOYEE:

(Last)

(First)

(Middle)

--Please print or type--

____________________________________________________________________________________________________

HOME ADDRESS:

(Street)

(City)

(Zip code)

DATE OF BIRTH: month _____________ day ___________ year ____________

4 digit PIN #: ________________________________________

(Reference Memorandum #823 for explanation)

This applicant began performing pest control services for this licensee on (DATE:) ___________________________________________

The primary pest control duties assigned to this employee are: __________________________________________________________

CHECK AND SIGN ONE STATEMENT ONLY:

(A)

I am not currently employed at any other pest control licensee in Florida. If previously employed by a Florida licensee, please provide the

TERMINATION DATE: month _______ day ______ year _____ and your JE number: ____________________________________

(B)

I am not currently employed at any other Florida pest control licensee and I will be a full time employee of the licensee performing the duties of the

certified operator in charge of:

[circle all that apply]

EFFECTIVE DATE: ________________________ CPO home/cell phone #: ______________________

(C)

I am a certified operator currently employed at _________________________________________________________________

applying for a SECOND ID CARD for exam experience in [circle the appropriate category]

_______________________________________________________ Date: ____________________

Original Signature of Applicant for ID card:

I DO HEREBY CERTIFY THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE,

INFORMATION AND BELIEF. I ALSO CERTIFY THAT THE APPLICANT HAS RECEIVED AT LEAST 5 DAYS OF FIELD TRAINING UNDER THE DIRECT

SUPERVISION OF A CERTIFIED OPERATOR AS REQUIRED BY SECTION 482.091(3), F.S.

______________________________________________________ JB/JF Number: _______________

Original Signature of Licensee or Certified Operator in Charge

_____________________________________________

___________________________________________________

(Please print Name)

(Date)

(Contact Phone number)

FDACS-13606 Rev. 07/14

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Application For Pest Control Employee-Identification Card Form - Florida Department Of Agriculture And Consumer Services

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