Resume Form - Supervisory Level Exam Requirement Page 4
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43.
Name of college attended_____________________________________________
Year graduated________________Major________________________________
Was this a two or four year college?_____________
Enclose verification (i.e. Copy of diploma
showing major, transcripts, etc.)
4.
Additional educational credit may be given for seminars, short courses, correspondence
courses, conferences and training meetings that are pertinent to the category(ies) for which you
are applying for, providing attendance is verified.
Enclose copies of course descriptions and Certificates of
Attendance
.
5.
Please complete the following information relating to experience working with pesticides. It is
your responsibility to provide us letters of reference or other documents verifying your work
experience.
A)
Firm______________________________________ Dates employed_____________________
Address
____________________________________________________________
(city, state, zip)
Supervisor’s name_________________________________ phone_______________________
Supervisor’s address
__________________________________________________
(city, state, zip)
Licensed in which category(ies)___________________________________________________
B)
Firm______________________________________ Dates employed_____________________
Address
____________________________________________________________
(city, state, zip)
Supervisor’s name_________________________________ phone_______________________
Supervisor’s address
__________________________________________________
(city, state, zip)
Licensed in which category(ies)___________________________________________________
The person designated to be the Principle Supervisory License Holder in NH hereby attests,
6.
by signature, that the applicant is designated by the company to be in a managerial or
supervisory position and actively supervising other employees applying pesticides.
______________________________________
_______________________
Principle Supervisor’s Signature
Date
**NOTE:
The decision concerning acceptance or denial of an applicant for the
supervisory exams is based on the information you supply. Incomplete forms will not be
accepted for consideration.**
______________________________________
_______________________
Applicant’s Signature
Date
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