Pesticide Training Course Roster

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44-14-2 (2/07)

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Send this original roster to: NYSDEC Pesticide Reporting & Certification Section within 21 Days after course completion. Make copy for sponsor’s records.

NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION DIVISION OF SOLID & HAZARDOUS MATERIALS BUREAU OF PESTICIDES MANAGEMENT 625 BROADWAY, ALBANY, NEW YORK 12233-7254

PESTICIDE TRAINING COURSE ROSTER
COURSE or SESSION TITLE SPONSOR DATE(S) OF COURSE (Beginning & Ending Dates) City State

COURSE NUMBER

NY - __ __ - __ __ __ __ __
CERTIFICATION ID #

LOCATION Street

**************************CREDIT WILL NOT BE GIVEN IF THE CERTIFICATION ID NUMBER IS OMITTED WHEN REQUIRED*************************** FIRST NAME MI LAST NAME SIGNATURE

I hereby verify that the above individuals and/or certified pesticide applicators/technicians have attended this course on date(s) so specified. Instructor’s Printed Name and Signature Title, Address, and Telephone Date

(VOID ALL BLANK SPACES WHEN SIGNED)