(PLEASE DO NOT PRINT AND MAIL IN THIS FORM! It is intended for ONLINE submission ONLY!)
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NOTE: This form is to apply for a NEW applicator license only and NOT for renewing an existing applicator licenses!!
NOTE:
Due to state network work the system may have connection issues Sunday May 23 between 12:00AM and 6:00AM

AZ Pest Management Division - New Applicator Application Form
Application
An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a license requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.

This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.

A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the agency’s adopted personnel policy.

This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
Full Legal Name:
Date of Birth (yyyy-mm-dd): 
Mailing Address\Contact Information:
     
We will use the zip code to attempt to fill in the City, State, and County. If we don't fill it in correctly please correct them.
   
Phone: ( -  
eMail:
License History\Priors:
Have you ever had any license or permit to practice pest control denied, revoked, or suspended? Yes   No
Prior Convections:
Has this applicant ever been convicted of a misdemeanor involving moral turpitude or any felony*?
(An offense that is undesignated, set aside, or has been expunged, is still considered a conviction. Please request and supply the information required on the Applicant with (Criminal Conviction Supplement.) If you have any doubt whether your type of conviction must be disclosed, disclose it for the Department to consider. Failure to disclose all relevant convictions may result in denial of certification.
Yes   No
Statement of lawful presence to receive public benefits:
Are you a citizen or national of the United States? Yes   No
Document for lawful presence
Upload the Document indicated above in PDF, or JPG (.pdf, or .jpg) format only. Not larger than 4MB please
This is Required
Front of Document:

Back of Document:
Not all documents will need the back
Note: Please No Spaces in the file Name use "First_Last.pdf or FirstLast.pdf" not "First last.pdf"