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Application for Photo ID Card

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Application for Photo ID Card Powered By Docstoc
					New York State Department of Environmental Conservation
Division of Solid & Hazardous Materials
Bureau of Pesticides Management
625 Broadway, Albany, New York 12233-7254
Phone: (518) 402-8748
Website: www.dec.ny.gov                                                                                          n
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              Certified Applicator/Technician Application for Photo ID Card
       Please TYPE or PRINT clearly and return this form to the address indicated on the bottom of this application




           First Name                M.I. Last Name                            Certification ID Number


                        IMPORTANT INFORMATION REGARDING YOUR PHOTO ID CARD

       The Department of Environmental Conservation (DEC) now produces certification photo ID Cards in
       cooperation with the NYS Department of Motor Vehicles (DMV). If you have a current NYS Driver License or Non-
       Driver ID Card, please provide your 9-digit DMV ID number in the space provided below. Then read and sign the
       informed consent below.

       If you don’t have a current NYS photo Driver License or Non-Driver ID Card, please have your photo taken at any
       DMV office and obtain a 9-digit DMV ID number BEFORE you complete this application.

                                                  INFORMED CONSENT

       I authorize the DEC and the DMV to produce an ID card bearing my DMV photo. I UNDERSTAND THAT THE
       DMV WILL SEND THIS CARD TO THE ADDRESS I MAINTAIN WITH THE DEC. I also understand that the
       DEC and DMV will use my DMV photo to manufacture all my subsequent ID Cards for as long as I maintain my
       certification with the DEC.




       DMV ID#




       X
           Applicant Signature                                          Date

       You will not receive your certification ID card until you return this application.

       Return to:
       New York State Department of Environmental Conservation
       Bureau of Pesticides Management
       625 Broadway
       Albany, NY 12233-7254

				
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