Request for Pesticide Course Recertification Credit Assignment
Complete this form to submit your pesticide education course for recertification credit approval at least 15 days prior to the course date.
Course Information
If your program spans more than one day, please enter the first day in the date field and list the remaining dates in the Additional Note field below.
Date of Course*:
Course Location Name*:
Website*:

Course Location Information
Address1*:
Address2:
City*: State*:
Zip*: County:
Country*:
*Verification of Address enables USAPlants to provide geocode coordinates for map location plotting.
Email:

Coordinator Information
State *:
- -
- -
- -

Agenda*
The agenda should include:
1.) Course topic subject matter information;
2.) Time allotted for each subject;
3.) Speakers name(s) And qualifications/biography

Additional Note

I understand that the credits assigned to this Pesticide Educational Recertification Course are based on the attached agenda information and may be adjusted based on actual course content. I will notify the Department of all changes to the attached agenda.

I understand that submitting information for pesticide recertification course approval is a legal process. Falsification by course sponsor responsible for this information provided, and/or the training conducted as pre-approved may result in the withdrawal of course approval, not only for the submitted course, but also for future courses, and the Department reserves the right to pursue further legal remedies.