Www.state.nj.us
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Department of Environmental Protection
COMMERCIAL PESTICIDE OPERATOR
RESPONSIBLE CERTIFIED APPLICATOR CHANGE FORM
Date:
On I,
date print name
Commercial Certified Pesticide Applicator License #
became the new Responsible Certified Applicator for the following Commercial Pesticide Operators:
Operator’s Name License #
1)
2)
3)
4)
5)
6)
7)
8)
9)
Print name of applicator business or employer applicator business license #
(leave blank if not an applicator business)
I am replacing the previous Responsible Certified Applicator,
print name & license #
Signature of new Responsible Certified Applicator
-----------------------
Chris Christie
Governor
Bob Martin
Commissioner
Pesticide Control Program – MC 401-04A
PO Box 420
Trenton, NJ 08625-0420
Phone: (609)530-4070 Fax: (609)984-6555
Website:
New Jersey is an Equal Opportunity Employer l Printed on Recycled Paper and Recyclable
KIM GUADAGNO
Lt. Governor
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