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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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