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** If you answer YES to questions 3, 4, 5, 6, 7, or 8 below; you must submit a
<br /> written explanation. (If you have previously provided the Department with this
<br /> information, you do not need to resubmit an explanation. Please indicate the
<br /> year it was submitted.) IF YOU FAIL TO SUBMIT THIS INFORMATION or you have had
<br /> recent actions taken against your registration that you have not previously
<br /> submitted an explanation for, your application will be denied.
<br /> 1. This business is operating as a : Sole Proprietorship: , Partnership: ,
<br /> Corporation: , Public Applicator: , Other (describe) :
<br /> 2 . List the person authorized to receive and accept service of summons and legal
<br /> notices of all kinds for the applicant in the state of Colorado. (Name, title,
<br /> and complete address)
<br /> Name Title Complete Address
<br /> 3. Has any action ever been taken regarding any registration, or equivalent
<br /> dealing with the application of pesticides, which you now hold or have ever
<br /> held? Include any actions by the U.S. military, U.S. Public Health Service, any
<br /> other U.S. federal Government entity, any state licensing board, tribe, or any
<br /> local authority. (Actions include but are not limited to: cease and desist
<br /> order, stipulation, suspension, revocation, fines, probation, practice
<br /> limitations, reprimand, letter of admonition, or other form of censure.) If
<br /> YES, attach an explanation; include state or government agency, date, charge
<br /> and disposition. _NO _YES
<br /> 4. Are there any complaints pending against any registration dealing with the
<br /> application of pesticides that are not addressed by your answers to question
<br /> three above? Is YES, attach an explanation. _NO _YES
<br /> 5. Have you ever been denied a registration or permission to apply pesticides in
<br /> any state, tribal, or U.S. federal jurisdiction? If YES, attach an explanation;
<br /> include state or government agency, date, charge and disposition. NO _YES
<br /> 6. Have you ever voluntarily surrendered a registration to apply pesticides in
<br /> Colorado? If YES, attach an explanation. NO _YES
<br /> 7. Have you ever been convicted of, received a deferred prosecution or a deferred
<br /> judgement for, or pled nolo conterdere to, any criminal offense related to the
<br /> application of pesticides in any state, tribal, or federal jurisdiction?
<br /> Include any conviction that has been set aside, dismissed, or pardoned under
<br /> any provision of the law. If YES, attach an explanation. _NO _YES
<br /> 8. Have you ever entered into a settlement or had a judgement entered against you
<br /> in a court of law for a misapplication of pesticides? If YES, attach an
<br /> explanation. _NO _YES
<br /> The undersigned states that the information contained in this application is
<br /> true and correct to the best of my knowledge. I also understand that under the
<br /> Pesticide Applicators' Act, providing false information is grounds for
<br /> registration denial, suspension, revocation, or other lawful discipline. The
<br /> undersigned also acknowledges that pursuant to 35-10-104 (1) (b) and (c) of the
<br /> Pesticide Applicators' Act, that as a limited commercial or public applicator,
<br /> whether they apply restricted use pesticides or have requested to be subject to
<br /> these provisions, upon signing this document they are subject to the provisions
<br /> of this article and to any rules and regulations adopted pursuant thereto.
<br /> Signature of Registrant or Authorized Representative Date
<br /> Printed Name of Registrant or Authorized Representative Title
<br />
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