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Application For A Pesticide Company License - Vermont Agency Of Agriculture, Food & Markets

Vermont Agency of Agriculture, Food & Markets

116 State St

Montpelier VT 05620-2901

802-828-2431

APPLICATION FOR A PESTICIDE COMPANY LICENSE

Authorized under 6 V.S.A Chapter 87 and regulations pertaining thereto. Request is hereby made for a pesticide

company license:

(must accompany this application)

Company License Fee: $75.00

COMPANY INFORMATION ***please print clearly***

Company # (for office use only)________

Business Name:

Secondary Business Name (optional)

Company website:

Company Officer:

Mailing Address line 1:

Address line 2:

Town:

State:

Zip:

Phone:

Fax:

Company Email:

Physical Location of

Certified Applicator(s) Employed

VERMONT Offices

(if different from address above)

CERTIFICATION OF COMPLIANCE WITH 15 V.S.A SECTION 795 AND 32 VSA SECTION 3113

I hereby certify that I am in good standing with respect to any obligations for child support and, that under the pains and penalties

of perjury, I am in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay

any and all taxes due to the State of Vermont as of the date of this application.

SIGNATURE:__________________________________________________Date:___________________

*FOR OFFICE USE ONLY*

Date__________ Amount__________

Cash □ Check □ Name___________

Rpt__________Initials_____________

Application For A Pesticide Company License - Vermont Agency Of Agriculture, Food & Markets