Applicator Application

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:

Social Security No:	Date of Birth (yyyy-mm-dd): Date of birth:
First Name:	Last Name:

Mailing Address\Contact Information:

Street Address:	Apt\Suite No:
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. Zip Code: City: State: County:
Phone:	() -
eMail:

License History\Priors:

Have you ever had any license or permit to practice pest control denied, revoked, or suspended?

Yes No

Prior Convictions:

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.
As of January 1, 2022
Pursuant to Arizona Revised Statute (A.R.S.) 3-3614 (C) – An individual who applies for certification as a new applicator or a new qualified applicator shall submit to the division a full set of fingerprints and fees as required by section 41-1750.
The director shall submit the fingerprints and fees to the Department of Public Safety for the purpose of obtaining a state and federal criminal records check pursuant to section 41-1750 and Public Law 92-544. The Department of Public Safety may exchange this fingerprint data with the Federal Bureau of Investigations.
All new Certified Applicator (CA) and Qualified Applicator (QA) Certification Applicants must complete and submit the following, in addition to their respective application and application fee:
Full set of fingerprints on the fingerprint card provided by the Pest Management Division
A cashier’s check or money order in the amount of $22.00 made payable to the Arizona Department of Public Safety (AZDPS). Personal checks cannot be accepted.
FBI Notification of Applicant Privacy Rights; and
Fingerprint Verification Form – must be completed by the Fingerprint Technician and sealed according to the instructions on the form.
Your CA or QA application cannot be processed until these documents are received. Please read the documents carefully so as not to delay the processing any further due to resubmissions.
The required documents may be submitted via mail or hand-delivery to the Arizona Department of Agriculture – Central Licensing located at 1688 West Adams Street in Phoenix Arizona 85007. They cannot be submitted electronically nor can they be submitted via any other agency.
Upon receipt of your background investigation report, you will be notified whether your application has been approved, denied, or more information is requested. If approved, you will receive an approval notification with instructions on how to proceed. If denied, you will receive a denial notification with instructions on how to proceed; including a notice of your rights to appeal. If additional information is requested, instructions will be provided via email (preferred, if possible) or hard copy.
If you have any questions or concerns, regarding the process, please feel free to contact us via email ([email protected]) or phone (602.542.3578)

Yes No

Statement of lawful presence to receive public benefits:

Are you lawfully present in the United States of America, by way of citizenship, national or alien status?	Yes No
Select the type of document you will upload as evidence of lawful presence in this country. All individual applicants for a license or certification covered by these laws must complete the following and provide evidence by submitting a copy (Front and Back, if any) of one or more documents from the lists below declaring your citizenship or lawful alien status with your application. If your documentation of lawful presence (including citizenship) does not have a photograph, you must also provide a government issued id with a photograph. If the Department has evidence you have previously submitted proof of United States citizenship or a non-expiring work authorization issued by the federal government, you do not have to do so again. Please DO NOT provide a copy of your Social Security Card.

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:
Front Photo Document (if a photo is not part of the Document):

Back Photo Document (if a photo is not part of the 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"