Pesticide Applicator Resume Form
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1R E S U M E F O R M
Individuals whom have two or more years of experience as a pesticide applicator in another state are also required
to pass the Massachusetts Applicator License (core) exam. They are NOT; however, required to wait the additional
two-years to upgrade their credential to one with certification categories. Such individuals should submit the below
resume form with their Commercial Certification Exam Application after they have received their Applicator License.
(PLEASE TYPE OR PRINT CLEARLY)
NAME: _____________________________________________________________________________
LAST
FIRST
MI
STREET ADDRESS: _________________________________________________________________
STREET
APT #
____________________________________________________________________________________
CITY
STATE
ZIP
COMPANY/EMPLOYER: ____________________________________________________________
(If Any)
Signature ____________________________________________________________Date___________________
All of the information on this form is true and complete to the best of my knowledge
Please mark with a check [√] the one category you intend to become certified in:
Category
MA State Code
Category
MA State Code
34
47
Aerial
Mosquito and Biting Fly Control
33
48
Agriculture
Regulatory
39
40
Aquatic
Right of Way
49
36
Demonstration and Research
Shade Tree and Ornamental
50
54
Food Processing
TBT
35
43
Forest
Termite/Structural Pest Control
42
37
Fumigation
Turf
41
44
General Pest Control
Vertebrate Pest Control
46
52
General Public Health
Wood Preservative
License History
(Attach additional sheets if necessary)
List or write in the years and categories you have held a certification or license in Massachusetts or another state.
Years Certified/Licensed
State(s)
Categories of Certification
Education History
Name of College(s) or
Technical school(s) attended_______________________________________________________________
one year
four year
certificate program
Other___________________________
Year graduated___________
Degree_________________
Major_________________
Please Enclose verification (i.e. copy of diploma, transcripts, etc.)
Additional educational credit may be given for seminars, short courses, correspondence courses, conferences or training meetings that
are pertinent to the category(ies) for which you are applying providing attendance is verified. Enclose copies of course descriptions and
Certificates of Attendance.
Pesticide Related Work History Experience
(Attach additional sheets if necessary)
Company/Employer _____________________________________Dates Employed_______________
Address___________________________________________________________________________
Supervisor’s Name and
Address__________________________________________________________________________
(if different from above)
________________________________________________________________________________
Licensed in Category(ies)_____________________________________________________________
13
REVISION DATE: 12/17/2015
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Parent category: Business