of Licensing and Enforcement Revenue Processing Section 407 S. Calhoun Street, Room 121 Tallahassee, FL 32399-0800 APPLICATION FOR PRIOR NOTIFICATION OF PESTICIDE APPLICATIONS Rule 5E-14.1055, F. A. C. Telephone (850) 617-7997 ADAM H. PUTNAM COMMISSIONER PART A – Pesticide Sensitive Individual Based on the information provided on the completed form below, including $50 initial registration fee - 001368 made payable to DACS, I request that my name be placed on the Florida Registry of Person.
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How to fill out the FL FDACS-13609 online
Filling out the FL FDACS-13609 form is essential for individuals who require prior notification of pesticide applications. This guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently.
Follow the steps to complete the FL FDACS-13609 form online.
- Click 'Get Form' button to obtain the FL FDACS-13609 form and open it in the editor.
- Begin with Part A: Pesticide Sensitive Individual. Indicate whether this is a new application or a renewal application by checking the appropriate box. Ensure you enter the date and sign where indicated.
- Provide your personal information in the fields labeled Last Name, First Name, Middle Initial, Primary Residence (Physical) Street Address, Apt. # (if applicable), Mailing Address (if different), City, Day Time Phone #, Night Time Phone #, Cell #, and Date of Birth.
- Fill in your County, and provide your Fax # if available. Ensure all information is typed or printed legibly.
- Move to Part B: Physician’s Medical Certification. If applicable, indicate your board certification status regarding Allergy, Occupational Medicine, or Toxicology, and specify the distance for notification that the physician recommends.
- The physician must sign and provide their name, license number, business address, date, and phone number.
- Complete Part C: adjacent properties. List properties that fall within the required notification distance. Use a separate sheet if additional addresses are necessary.
- Finally, review all sections for completeness and accuracy. You may save changes or download the completed form.
- Once verified, submit the form along with the required fee through the designated payment method. Ensure you have all necessary copies for your records.
Begin completing your FL FDACS-13609 form online today to ensure you receive prior notification of pesticide applications.
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