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For qualification. Send to: Department of Pesticide Regulation, Pest Management and Licensing Branch, Licensing and Certification Program, P.O. Box 4015, Sacramento, California 95812-4015. Name (Last, First, M.I.): Address: City/State/Zip Code: Name of Firm/Organization: Business Telephone Number: ( ) Fax Number: ( ) Qualification Method: Indicate the method of qualification and attach a copy of the evidence used for qualification. Requests for approval of Other trainer qualification.

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