NAME (Last, First, Middle) PLEASE PRINT CLEARLY LICENSE NUMBER BIRTHDATE

MONTH DAY YEARHOME MAILING ADDRESS (PO Box or Street Address) HOME TELEPHONE NO.

CITY STATE ZIP CODE E-MAIL ADDRESS

COMPANY / AGENCY NAME COMPANY/AGENCY TELEPHONE NO.

COMPANY / MAILING ADDRESS (PO Box or Street, City, State, Zip)

If you are applying for a renewal after January 1 and you have not performed work requiring your license(s), you are exempt from the penalty fee. You must sign the statement below verifying your exemption status.I hereby state that I have not operated as a

__________________________________________________________LIST ALL LICENSES FOR WHICH THIS EXEMPTION APPLIES

since the expiration of my last license and am therefore exempt from the penalty fee(s).

__________________________________________________________SIGNATURE OF APPLICANT DATE

CASHIER USE ONLY

Pesticide Management DivisionPO Box 42591Olympia, WA 98504-2591Toll Free 877-301-4555E-mail: license@agr.wa.gov

OFFICE USE ONLY

ISSUED: __________________________

AGR-4280A (R/9/20) Page 1 of 2

SECTION 1 – LICENSES TO RENEW RENEWAL FEE

TOTAL LICENSE FEE(S) $ __________________________

PENALTY FEE(S) $ __________________________

TOTAL REMITTANCE $ __________________________Make checks payable to WSDA. Please do not send cash. Checks returned by the bank will be charged a handling fee of $25.00 (RCW 62A.3.515(a) and 62A.3.520.).

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PENALTY FEE EXEMPTION STATEMENT DECLARACIÓN DE EXCEPCIÓN DE PAGO DE MULTA

APPLICATION METHOD(Check all that apply)

AIR GROUND CHEMIGATIONDo you apply fertilizers through irrigation equipment? Yes

LICENSE TYPE FEE PENALTY FEE*

Commercial Operator .......................... $67 ............ $67 Private Commercial ............................. $33 ............ $33 Commercial Consultant ...................... $60 ............ $60 Public Consultant ................................ $33 ............ $33 Demo & Research ................................ $33 ............ $33 Structural Pest Inspector* ...................... $60 ............ $60 Dealer Manager ..................................... $33 ............ $33 Public Operator ...................................... $33 ............ $33 Private Applicator (PA) ........................... $33 ............ $33 Limited Private Applicator (LPA) ............ $33 ............ $33 Rancher Private Applicator (RPA) .......... $100........... $25

(Note: No fee required for PA, LPA or RPA license if renewingany other WSDA pesticide license for which a fee is paid.)*see instructions #3 above

(1) Mark license(s) you wish to renew in Section 1. Note: WSDA has an online renewal option: https://fortress.wa.gov/agr/apps/PMLicRenewal/ (2) Determine fee. Renewals submitted after January 1 require the penalty fee in addition to the license fee indicated or completion of the

penalty fee exemption statement at the bottom of this form.(3) FeeforStructuralPestInspectorlicenseisnotrequiredifrenewinganyoneofthefivelicensetypesinbold.(4) Select Application Method (if applicable). Complete Section 2 - Applicant Information.(5) Please send completed form with appropriate fee to WSDA at the address above.

PESTICIDE/SPI LICENSE RENEWAL APPLICATION

7101

7102

Si usted está solicitando renovar su licencia después de 1ro de enero y no realizado ningún trabajo que requería su(s) licencia(s), usted está excepto de pagar la multa. Usteddebefirmarlasiguientedeclaraciónparaverificarsuestatusdeexcepción.Yo declaro por este medio que no he operado

_________________________________________________________________ANOTE TODAS LAS LICENCIAS QUE CALIFICAN PARA ESTA EXCEPCIÓN

desde la expiración de mi licencia, y por tanto, estoy excepto de pagar la(s) multa(s).

_________________________________________________________________FIRMA DEL SOLICITANTE FECHA

INSTRUCTIONS

Yes, I need a new plastic card

SECTION 2 – APPLICANT INFORMATION

AGR-4280A (R/9/20) Page 2 of 2

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WSDA Pesticide License TypesNote: All licenses expire annually on December 31, with the exception of Limited & Rancher Private

Applicator licenses, which are five year licenses expiring on December 31 of the fifth year.LICENSE TYPE DEFINITIONSCommercial Operator A person employed by a commercial applicator to apply pesticides to the land of Fee: $67.00 another. This land can either be publicly or privately owned. The commercial operator license is not valid unless working for a licensed commercial applicator.

Commercial Applicator A person engaged in the business of applying pesticides to the land/property of Fee: $215.00 another. This land can either be publicly or privately owned. NOTE: Use "Commercial Pesticide Applicator License Application" (AGR 702-4241) to apply for this license.

Structural Pest Inspector A person who inspects a structure for wood destroying organisms or conditions Fee: $60.00 conducive to their development. Wood destroying organisms include carpenter and moisture ants, termites, wood infesting beetles and wood rot (fungus). This license is required in addition to any license needed to apply, consult or distributepesticides.Proofoffinancialcoveragerequired.Gotoagr.wa.gov for further information.

Private-Commercial Applicator A person who applies or supervises the use of a "restricted use" pesticide on Fee: $33.00 land owned or rented by him or his employer for purposes other than the production of an agricultural commodity.

Dealer Manager A person who supervises the distribution of pesticides (other than home and gar- Fee: $33.00 den products) from a pesticide dealer outlet. The dealer manager license is not valid unless working for a licensed Pesticide Dealer outlet.

Public Operator A person who, while acting as an employee of a governmental agency, applies Fee: $33.00 "restricted use" pesticides by any means or general use pesticides by power equipment on public or private property. The public operators license is not valid unless working for a public agency.

Public Pest Control Consultant Apersonwho,whileactingasanemployeeofagovernmentalagency,offersor Fee: $33.00 supplies technical advice, supervision, aid or makes recommendations to any user of non-home and garden pesticides. The public pest control consultant license is not valid unless working for a public agency.

Commercial Pest Control Apersonwhosellsorofferspesticidesforsaleatotherthanthelicensedpesti- Consultant cide dealer outlet from which they are employed. In addition, commercial consultants Fee:$60.00 mayofferorsupplytechnicaladvice,aid,ormakerecommendationstotheusers of non-home and garden pesticides. Licensed and employed commercial applica- tors and commercial operators may act as commercial consultants without acquiring the license.

Demonstration & Research A person who applies or supervises the use of any experimental use pesticide or Fee: $33.00 any "restricted use" pesticide at no charge to small experimental plots for re- search purposes.

Private Applicator A person who applies or supervises the use of any pesticide through chemigation Fee: $33.00 equipment or a "restricted use" pesticide on land owned or rented by him or his employer for the purpose of producing an agricultural commodity. No fee required if applicant pays for another qualifying WSDA pesticide license.

Limited Private Applicator Both licenses allow holder to apply or supervise the use of restricted use Fee: $33.00 herbicides on non-production agricultural land (pastures, rangeland, areas around Rancher Private Applicator farm buildings) and in mixed rangeland-timber areas to control weeds designated Fee: $100.00 for mandatory control. Rancher Private Applicators may also apply herbicides and rodenticides to limited production agricultural land where hay and grain are grown primarily for on-farm use. Neither license allows the use of restricted use insecticides, fungicides or aquatic herbicides. No fee required for either license if applicant pays for another qualifying WSDA pesticide license. Both are valid in Eastern Washington only.

* The fee is not required if applicant holds and is working under the authority of a current Commercial Applicator, Commercial Operator, Private Commercial Applicator, Commercial Consultant, Demonstration & Research, Public Operator or Public Consultant license.

Public agency purchase orders are not accepted. State agencies may pay with a journal voucher (JV) crediting agency 495, fund 126.

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YEAR: 2021