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Gov/pesticides. asp To apply for a new or to renew a Private Pesticide Applicator Certification mail this form with your check in the amount of 15 payable to IDALS to the address above. Test scores are good for one year from the date testing completed. It is strongly recommend that you keep a copy for your records. A certification is not valid until the fee is paid. Check box if you are a student. Test Date Test Location Print legibly one letter per box. APPLICATION FOR PRIVATE PESTICIDE APPLICATOR CERTIFICATION Iowa Department of Agriculture Land Stewardship Pesticide Bureau Henry A. Wallace Building Des Moines Iowa 50319-0051 pesticides iowaAgriculture. gov http //www. iowaagriculture. gov/pesticides. asp To apply for a new or to renew a Private Pesticide Applicator Certification mail this form with your check in the amount of 15 payable to IDALS to the address above. Test scores are good for one year from the date testing completed* It is strongly recommend that you keep a copy for your records. A certification is not valid until the fee is paid* Check box if you are a student. Test Date Test Location Print legibly one letter per box. Leave one space between words Please check one New certification Renewal certification Social Security Number Required for new applications Last 4 acceptable for renewals Last Name First Name Middle Initial Street Address City Zip Code 4 State Telephone Area Code and Number County of Residence Applicant Signature Applicant DO NOT WRITE BELOW THIS LINE Test Score Private Applicator - 1 I hereby attest that this applicant has successfully completed the private pesticide applicator certification examination and I have verified the identity of this applicant by observing a photo-identification* Test Proctor Signature Date Validation Code 66 Form 009-0841 rev 2-2011. APPLICATION FOR PRIVATE PESTICIDE APPLICATOR CERTIFICATION Iowa Department of Agriculture Land Stewardship Pesticide Bureau Henry A. Wallace Building Des Moines Iowa 50319-0051 pesticides iowaAgriculture. gov http //www. iowaagriculture. Wallace Building Des Moines Iowa 50319-0051 pesticides iowaAgriculture. gov http //www. iowaagriculture. gov/pesticides. asp To apply for a new or to renew a Private Pesticide Applicator Certification mail this form with your check in the amount of 15 payable to IDALS to the address above. gov/pesticides. asp To apply for a new or to renew a Private Pesticide Applicator Certification mail this form with your check in the amount of 15 payable to IDALS to the address above. Test scores are good for one year from the date testing completed* It is strongly recommend that you keep a copy for your records. Test scores are good for one year from the date testing completed* It is strongly recommend that you keep a copy for your records. A certification is not valid until the fee is paid* Check box if you are a student. Test Date Test Location Print legibly one letter per box. A certification is not valid until the fee is paid* Check box if you are a student. Test Date Test Location Print legibly one letter per box. Leave one space between words Please check one New certification Renewal certification Social Security Number Required for new applications Last 4 acceptable for renewals Last Name First Name Middle Initial Street Address City Zip Code 4 State Telephone Area Code and Number County of Residence Applicant Signature Applicant DO NOT WRITE BELOW THIS LINE Test Score Private Applicator - 1 I hereby attest that this applicant has successfully completed the private pesticide applicator certification examination and I have verified the identity of this applicant by observing a photo-identification* Test Proctor Signature Date Validation Code 66 Form 009-0841 rev 2-2011.