Fillable Printable Voluntary Field Worker Training Verification Program Application / Agreement - California
Fillable Printable Voluntary Field Worker Training Verification Program Application / Agreement - California
Voluntary Field Worker Training Verification Program Application / Agreement - California
revised 05/06arg
DEPARTMENT OF PESTICIDE REGULATION
VOLUNTARY FIELD WORKER TRAINING VERIFICATION PROGRAM
APPLICATION/AGREEMENT
Directions: Complete and sign this application and attach a copy of the evidence used
for qualification. Send to:
Department of Pesticide Regulation, Pest Management and Licensing Branch,
Licensing and Certification Program,
P.O. Box 4015, Sacramento, California 95812-4015.
Name (Last, First, M.I.):
Address:
City/State/Zip Code:
Name of Firm/Organization:
Business Telephone Number: ( ) Fax Number: ( )
Qualification Method: Indicate the method of qualification and attach a copy of the
evidence used for qualification. Requests for approval of “Other trainer qualification”
should be a letter and resume describing how you meet the fieldworker trainer
qualifications in Section 6764 Title 3, California Code of Regulations.
F California Certified Private Applicator
F California Certified Commercial Applicator (Qualified Applicator License, Qualified
Applicator Certificate, Journeyman Pilot Certificate)
F Other DPR-issued qualification (Pest Control Dealer Designated Agent License,
Apprentice Pilot Certificate)
F California licensed Agricultural Pest Control Adviser
F County Biologist License (Pesticide Regulation or Investigation and
Environmental Monitoring issued by the Department of Food and Agriculture)
F Currently Employed as a Farm Adviser with University of California Extension
F California Registered Professional Forester
F UCIPM Instructor Training Certificate (Issued on or after 1/1/93)
F UC Extension Instructor Training Certificate
F Other DPR-approved trainer qualification
F Other trainer qualification
revised 05/06arg
I agree to issue U.S. EPA pesticide safety training verification cards to agricultural field
workers only in compliance with the following requirements. I will:
(a) Issue U.S. EPA training verification cards only to trainees who are or have been
trained according to requirements of the 1992 Federal Worker Protection Standard
(40 CFR, Part 170.130).
(b) Use training materials developed or approved by U.S. EPA according to any
instructions provided.
(c) Record trainee information on the verification cards in ink or other indelible form.
(d) Retain for five (5) years, a copy of a class roster, signed by the trainer and each
trainee, indicating the card number issued to each trainee and the date and
address of the location where the training occurred.
(e) Issue U.S. EPA training verification cards that match U.S. EPA specifications.
(f) Respond promptly to requests from U.S. EPA, DPR, county agricultural
commissioners, or agricultural employers for information concerning U.S.
EPA-issued training verification cards.
(g) If I decide to terminate this agreement, I will return any unused cards and the
records described above to DPR.
Number of Training Verification Cards Requested:
Signature: Date:
DEPARTMENT USE ONLY
F APPROVED F DISAPPROVED
NUMBER OF TRAINING VERIFICATION CARDS ISSUED:
SIGNATURE: DATE:
