Get Alabama Department Of Agriculture Application For Professional Services Permit

PLEASE MAKE CHECK PAYABLE TO THE ALABAMA DEPT OF AGRICULTURE FOR OFFICE USE ONLY - DO NOT WRITE BELOW THIS LINE PERMIT NUMBER PS-M- Permit Fee AGRICULTURE OFFICE STAFF USE Category Fee s Contract s Approved Yes No Penalty Insurance Up-to-date Yes Total Bond Received Date Processed Cash Check MO. Print Form Alabama Department of Agriculture and Industries APPLICATION FOR PROFESSIONAL SERVICES PERMIT STRUCTURAL PEST CONTROL MAIN OFFICE Return to Date DEPARTMENT OF AGRICULTURE INDUSTRIES PESTICIDE MANAGEMENT - PROFESSIONAL SERVICES 1445 FEDERAL DRIVE MONTGOMERY AL 36107-1123 PHONE 334-240-7261 FAX 334-240-7168 County ATTENTION Application for Professional Services Permit as required under provisions of Chapter 28 Title 2 Code of Alabama 1975 as amended. PERMIT FEE 175. 00 PLUS 100. 00 FOR EACH CATEGORY OF WORK CERTIFIED TO PERFORM. A 50. 00 DELINQUENT PENALTY IS REQUIRED IF APPLICATION IS NOT POSTMARKED BEFORE NOVEMBER 1. PENALTY does not apply to NEW BUSINESS* EXISTING BUSINESSES REAPPLYING FOR A PERMIT MAY BE SUBJECT TO CIVIL PENALTY PROVISIONS UP TO 3000. 00 FOR PERFORMING OR SOLICITING PROFESSIONAL SERVICES WORK WITHOUT A PERMIT IF THE APPLICATION IS NOT POSTMARKED BEFORE JANUARY 1. IF APPLICATION IS SUBMITTED WITH OTHER LICENSE/PERMIT FEES PLEASE SUBMIT SEPARATE CHECKS* CHECK CERTIFIED CATEGORY IES BELOW Household institutional industrial Pest Control HPC Fumigation Pest Control FC Control and/or Eradication of Wood Destroying organisms WDC NAME OF BUSINESS CALL TO VERIFY NAME IS AVAILABLE PHONE LOCATION ZIP CODE MAILING ADDRESS NEW BUSINESS FAX ADD-ON CATEGORY to Permit PS-M- RENEWAL OUT OF BUSINESS BUY OUT NAME CHANGE - OLD BUSINESS NAME LIST CERTIFIED SUPERVISOR S Additional names can be attached for those that passed exams and are certified* No additional fees are required* The Certified Operator is responsible for work performed by permittee. LEGAL NAME COMMERCIAL CERTIFICATION SS NUMBER CATEGORY EXPIRATION DATE INSURANCE HPC/WDC/FC BOND FOR WDC ONLY THIS INFORMATION APPLIES TO NEW BUSINESSES ONLY INSURANCE EXPIRATION DATE IF WDC attach copy of CERTIFICATE OF LIABILITY INSURANCE ORIGINAL SURETY BOND and copy of CONTRACT. If HPC/FC attach Certification of Insurance form SURETY BOND EXPIRATION DATE APPLICANT WILL ENGAGE IN BUSINESS AS Sole Owner Partnership Corporation SIGNATURE TITLE APPLICATION MUST BE SIGNED. 00 PLUS 100. 00 FOR EACH CATEGORY OF WORK CERTIFIED TO PERFORM. A 50. 00 DELINQUENT PENALTY IS REQUIRED IF APPLICATION IS NOT POSTMARKED BEFORE NOVEMBER 1. PENALTY does not apply to NEW BUSINESS* EXISTING BUSINESSES REAPPLYING FOR A PERMIT MAY BE SUBJECT TO CIVIL PENALTY PROVISIONS UP TO 3000. PENALTY does not apply to NEW BUSINESS* EXISTING BUSINESSES REAPPLYING FOR A PERMIT MAY BE SUBJECT TO CIVIL PENALTY PROVISIONS UP TO 3000. 00 FOR PERFORMING OR SOLICITING PROFESSIONAL SERVICES WORK WITHOUT A PERMIT IF THE APPLICATION IS NOT POSTMARKED BEFORE JANUARY 1. 00 FOR PERFORMING OR SOLICITING PROFESSIONAL SERVICES WORK WITHOUT A PERMIT IF THE APPLICATION IS NOT POSTMARKED BEFORE JANUARY 1. IF APPLICATION IS SUBMITTED WITH OTHER LICENSE/PERMIT FEES PLEASE SUBMIT SEPARATE CHECKS* CHECK CERTIFIED CATEGORY IES BELOW Household institutional industrial Pest Control HPC Fumigation Pest Control FC Control and/or Eradication of Wood Destroying organisms WDC NAME OF BUSINESS CALL TO VERIFY NAME IS AVAILABLE PHONE LOCATION ZIP CODE MAILING ADDRESS NEW BUSINESS FAX ADD-ON CATEGORY to Permit PS-M- RENEWAL OUT OF BUSINESS BUY OUT NAME CHANGE - OLD BUSINESS NAME LIST CERTIFIED SUPERVISOR S Additional names can be attached for those that passed exams and are certified* No additional fees are required* The Certified Operator is responsible for work performed by permittee.