Weed and Pest Control Permit Exam Application

Mississippi Department of Agriculture & Commerce • Bureau of Plant Industry

Applicant Information

Name#text(#field(17721)) #if(#field(17722))#text(#field(17722)) #endif#text(#field(17723))
Phone#text(#field(17724))
Email#text(#field(17725))

Physical Address

#text(#field(17726))
#if(#field(17727))
#text(#field(17727))
#endif
#text(#field(17728)), #text(#field(17729)) #text(#field(17730))

Mailing Address

#if("#text(#field(17731))" == "Mailing address is same as physical address")Mailing address is same as physical address.#endif#if("#text(#field(17731))" != "Mailing address is same as physical address")
#text(#field(17732))
#if(#field(17733))
#text(#field(17733))
#endif
#text(#field(17734)), #text(#field(17735)) #text(#field(17736))
#endif

Commercial Certification

#if("#text(#field(17783))" == "Yes")#endif
Certified in MS or another state in the appropriate categories?#text(#field(17783))
Certified in the State of#text(#field(17776))
Commercial certification number#text(#field(17777))
Proof of certification — Front#text(#field(17779))
Proof of certification — Back#text(#field(17780))

Employment Information

Employer Company Name#text(#field(17740))
Company Address
#text(#field(17741))
#if(#field(17742))
#text(#field(17742))
#endif
#text(#field(17743)), #text(#field(17744)) #text(#field(17745))
Company Phone#text(#field(17746))
Dates of Employment#text(#field(17747)) to #text(#field(17748))
Title of Applicant#text(#field(17749))
MS Registered Technician ID ##text(#field(17750))
Category(ies) on RT ID#checkbox_label(17751, ", ")

Examination Categories

Selected Categories#checkbox_label(17755, ", ")

Operator License Holder

Operator ID ##text(#field(17772))
Categories#checkbox_label(17774, ", ")
Submission ID: #submit_id
Page: #post_title
URL: #post_url