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X: (804) 443-4534 Application Fee $100.00 Enclose check or money order Payable to Treasurer of Virginia 1. NUTRIENT MANAGEMENT CATEGORY Agriculture Turf & Landscape Both If both, are you currently certified as a VA NM Planner? 2. For Agency Use Only 4/12 Date App. Rec d Check Number Check Date DCR Receipt DCR Date Exam Date APPLICANT Yes No If yes, Certification # Driver s License ID #: Name: Address: Phone #: City State Zip E-Mail Address: 3. EMPLOYMENT/BUSINESS INF.

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