TRUCTURAL EST ONTROL OARD ICENSING NIT VERGREEN TREET TE ACRAMENTO CA WWW PESTBOARD - PDF document

�� &#x/Att;¬he; [/;ott;&#xom ];&#x/Sub;&#xtype;&#x /Fo;&#xoter;&#x /Ty;&#xpe /;&#xPagi;&#xnati;&#xon 0;&#x/Att;¬he; [/;ott;&#xom ];&#x/Sub;&#xtype;&#x /Fo;&#xoter;&#x /Ty;&#xpe /;&#xPagi;&#xnati;&#xon 0; ϯ �IO�ATION OF THE SECU�ITY OF THE E�A�INATION, INC�UDING CHEATING ON AN E�A�INATION, IS A �ISDE�EANO� IF YOU A�E FOUND GUI�TY, YOU COU�D �ECEI�E A FINE, A JAI� SENTENCE O� BOTH. IT IS A�SO �EASON FO� DISQUA�IFICATION F�O� THE E�A�INATION AND DENIA� OF A �ICENSE. IF YOU �IO�ATE THE SECU�ITY OF THE E�A�INATION AND A�E FOUND GUI�TY, IN ADDITION TO OTHE� PENA�TIES, YOU WI�� BE HE�D �IAB�E FO� ACTUA� DA�AGES CAUSED TO THE ST�UCTU�A� PEST CONT�O� BOA�D FO� UP TO $10,000 AND THE COSTS OF �ITIGATION �BUSINESS AND P�OFESSIONS CODE SECTION 123). SO�E �IO�ATIONS OF E�A�INATION SECU�ITY A�E: �emoving examination mate�ia�s f�om examination �ooms Copying any po�tion of the examination mate�ia�s Ta�king to any othe� candidate du�ing the examination Copying answe�s f�om anothe� candidate A��owing anothe� pe�son to copy you� answe�s Having books, notes, etc. du�ing the examination Taking the examination fo� someone e�se �etting someone e�se take you� examination �emo�izing questions o� answe�s f�om the examination to sha�e with othe�s Getting examination questions o� othe� mate�ia�s befo�e, du�ing o� afte� the examination Se��ing, buying, �eceiving any po�tion of a futu�e, cu��ent o� p�evious�y administe�ed examination The info�mation on this app�ication is �equi�ed pu�suant to Sections 8560 and fo��owing of the Business and P�ofessions Code. A�� info�mation �equested in this app�ication is mandato�y, none is vo�unta�y. Fai�u�e to p�ovide any of the �equested info�mation wi�� �esu�t in the app�ication being �ejected as incomp�ete. The info�mation you fu�nish wi�� be used to dete�mine whethe� you do o� do not meet the �equi�ements fo� which you a�e app�ying. The info�mation you p�ovide may be t�ansfe��ed to othe� gove�nmenta� and �aw enfo�cement agencies and may be disc�osed upon a Pub�ic �eco�ds Act �equest made pu�suant to Section 6250 of the Gove�nment Code. You have a �ight of access to �eco�ds maintained by this agency which contain pe�sona� info�mation about you subject to the p�ovisions of the Info�mation P�actices Act. �§1798 et. seq of the Civi� Code) The info�mation is maintained by the St�uctu�a� Pest Cont�o� Boa�d, 2005 Eve�g�een St�eet, Suite 1500, Sac�amento, CA 95815-3831; te�ephone 916/561-8704. The �egist�a� of the Boa�d is the Custodian of �eco�ds. CE�TIFIED T�UE STATE�ENT I have �ead and unde�stand the above and I ce�tify unde� pena�ty of pe�ju�y unde� the �aws of the State of Ca�ifo�nia to the t�uth and accu�acy of a�� statements and �ep�esentations made in this app�ication, inc�uding a�� statements attached he�eto. I unde�stand that fa�sifying info�mation on this app�ication may �esu�t in the denia� of this app�ication. O�igina� Signatu�e of App�icant Attach 2´ x 2" photo he�e I�PO�TANT NOTE: �EFE� TO SECTION 8562 OF THE BUSINESS AND P�OFESSIONS CODE TO ENSU�E YOU �EET THE E�IGIBI�ITY �EQUI�E�ENTS FO� �ICENSU�E. This app�ication must be comp�eted in acco�dance with the inst�uctions p�ovided on the fi�st page of this app�ication. Be su�e you a�e p�epa�ed fo� the examination befo�e comp�eting this app�ication. �ack of p�epa�ation is not conside�ed a va�id �eason fo� postponement, as p�ovided in section 1941 of the �u�es and �egu�ations. Such �equest wi�� be denied and the examination fee fo�feited. Disc�osu�e of you� socia� secu�ity numbe� �SSN) o� Individua� Tax identification Numbe� �ITIN) is mandato�y. Section 30 of the Business and P�ofessions Code and Pub�ic �aw 94-455 �42 USCA 405�c)�2)�C)) autho�ize co��ection of you� SSN o� ITIN. You� SSN o� ITIN wi�� be used exc�usive�y fo� tax enfo�cement pu�poses, fo� pu�poses of comp�iance with any judgment o� o�de� fo� fami�y suppo�t in acco�dance with Fami�y Code Section 17520, o� fo� ve�ification of �icensu�e o� examination status by a �icensing o� examination entity which uti�izes a nationa� examination and whe�e �icensu�e is �ecip�oca� with the �equesting state. If you fai� to disc�ose you� SSN o� ITIN, you� app�ication fo� examination wi�� not be p�ocessed AND you wi�� be �epo�ted to the F�anchise Tax Boa�d, which may assess a $100 pena�ty against you. If you have any questions �ega�ding the app�ication fo� examination, contact the Examination/�icensing Unit. ��ϰ NOTICE ON CO��ECTION OF PE�SONA� INFO��ATION Co��ection and Use of Pe�sona� Info�mation The St�uctu�a� Pest Cont�o� Boa�d of the Depa�tment of Consume� Affai�s co��ects the pe�sona� info�mation �equested on this fo�m as autho�ized by Business and P�ofessions Code Section 8560 and the Info�mation P�actices Act. The St�uctu�a� Pest Cont�o� Boa�d uses this info�mation p�incipa��y to identify and eva�uate app�icants fo� �icensu�e, issue and �enew �icenses, enfo�ce �icensing standa�ds set by �aw and �egu�ation, update and maintain cu��ent �icensee info�mation, and fo� mai�ing pu�poses. �andato�y Submission Submission of the �equested info�mation is mandato�y. The St�uctu�a� Pest Cont�o� Boa�d cannot conside� you� app�ication fo� �icensu�e o� �enewa� un�ess you p�ovide a�� of the �equested info�mation. Access to Pe�sona� Info�mation You may �eview the �eco�ds maintained by the St�uctu�a� Pest Cont�o� Boa�d that contain you� pe�sona� info�mation, as pe�mitted by the Info�mation P�actices Act. See be�ow fo� contact info�mation. Possib�e Disc�osu�e of Pe�sona� Info�mation We make eve�y effo�t to p�otect the pe�sona� info�mation you p�ovide us. The info�mation you p�ovide, howeve�, may be disc�osed in the fo��owing ci�cumstances: In �esponse to a Pub�ic �eco�ds Act �equest �Gove�nment Code Section 6250 and fo��owing), as a��owed by the Info�mation P�actices Act �Civi� Code Section 1798 and fo��owing); To anothe� gove�nment agency as �equi�ed by State o� Fede�a� �aw; o�, In �esponse to a cou�t o� administ�ative o�de�, a subpoena, o� a sea�ch wa��ant. Contact Info�mation Fo� questions about this notice o� access to you� �eco�ds, you may contact: The St�uctu�a� Pest Cont�o� Boa�d at 2005 Eve�g�een St�eet, Suite 1500, Sac�amento, CA 95815, by phone at �916) 561-8704, o� by emai� at pestboa�d@dca.ca.gov. Fo� questions about the Depa�tment¶s P�ivacy Po�icy, you may contact the Depa�tment of Consume� Affai�s at 1625 No�th �a�ket Bou�eva�d, Sac�amento, CA 95834, by phone �800) 952-5210, o� by emai� at dca@dca.ca.gov ��Ϯ 7.A�e you 18 yea�s of age o� o�de�? YES 8.Have you eve� app�ied fo� the fie�d �ep�esentative o� ope�ato�¶s examination? YES If YES, when? 9.A�e you p�esent�y �icensed o� have you p�evious�y been �icensed as an app�icato�,a fie�d �ep�esentative o� an ope�ato� in the State of Ca�ifo�nia? YES NO If YES, state �icense numbe��s) 10Do you have any pending discip�ina�y action against you in �ega�dsto a st�uctu�a� pest cont�o� p�ofessiona� o� vocationa� �icense? YES NO If YES, attach a detai�ed statement. 11.A�e you now o� have you eve� been a pa�tne� in a company o� anoffice� of aco�po�ation �icensed by the St�uctu�a� Pest Cont�o� Boa�d? YES NO If YES, �ist name�s) of companies 12.Have you, o� any company with which you have been affi�iated, had ap�ofessiona� o�vocationa� �icense denied, suspended, o� �evoked by this o� any othe� state? YES NO If YES, attach a detai�ed statement. 13.Have you eve� been convicted of any vio�ation of any p�ovision of theSt�uctu�a� Pest Cont�o� Act? YES If YES, attach a detai�ed statement. A�e you now o� have you eve� �icensed to do st�uctu�a� pest cont�o� in anothe� State? YES NOIf YES, you wi�� be �equi�ed to submit a ce�tified �icense histo�y f�om that State¶s �icensing Agencyas we�� as a copy of that State¶s �u�es and �egu�ations befo�e the issuance of a �icense. EDUCATION �EQUI�E�ENT - In acco�dance with Section 8565.5 of the St�uctu�a� Pest Cont�o� Act, an app�icant must submit p�oof satisfacto�y to the Boa�d that he/she has satisfacto�i�y passed boa�d app�oved cou�ses in the a�eas out�ined unde� the b�anch the app�icant is app�ying fo� �icensu�e. Attached is a �ist of boa�d app�oved cou�ses that have been app�oved to fu�fi�� the �equi�ements of Section 8565.5 of the St�uctu�a� Pest Cont�o� Act. Anyone who has comp�eted cou�ses that he/she fee�s meets the c�ite�ia out�ined be�ow but have not been app�oved by the Boa�d, may submit info�mation on the cou�ses within his/he� app�ication. Thei� cou�ses wi�� be �eviewed on an individua� basis. B�anch 1 - An app�icant fo� the Ope�ato��s B�anch 1 �icense must attach p�oof satisfacto�y to the Boa�d that he/she has satisfacto�i�y passed boa�d app�oved cou�ses in the fo��owing a�eas: Pesticides �u�es and �egu�ations Cont�act �aw Pest Identification and Bio�ogy Business P�actices Fumigation Safety B�anch 2 -An app�icant fo� the Ope�ato��s B�anch 2 �icense must attach p�oof satisfacto�y to the Boa�d that he/she has satisfacto�i�y passed boa�d app�oved cou�ses in the fo��owing a�eas: Pesticides Cont�act �aw Business P�actices Pest Identification and Bio�ogy �u�es and �egu�ations B�anch 3 - An app�icant fo� the Ope�ato��s B�anch 3 �icense must attach p�oof satisfacto�y to the Boa�d that he/she has satisfacto�i�y passed boa�d app�oved cou�ses in the fo��owing a�eas: Pesticides �u�es and �egu�ations Cont�act �aw Pest Identification and Bio�ogy Business P�actices Const�uction �epai� and P�ese�vation Techniques � T�UCTU�A� EST ONT�O� OA�D-�ICENSING �E�G�EEN T�EET1500AC�A�ENTO916--8704 -263- PESTBOA�DGO� APP�ICATION FO� ST�UCTU�A� PEST CONT�O� OPE�ATO� E�A�INATION FEE $65 PE� B�ANCH ��emit by money o�de�, cashie��s, pe�sona� o� ce�tified check payab�e to the St�uctu�a� Pest Cont�o� Boa�d.) FO� BOA�D USE ON�Y Cashie�ing No. �esu�ts INST�UCTIONS: Each question must be fu��y and t�uthfu��y answe�ed.Attach sheets to this app�ication whe�eve� so di�ected o� when space p�ovided is not sufficient.An incomp�ete app�ication wi�� be �etu�ned to the app�icant.A $65 Examination Fee pe� b�anch is �equi�ed.A�� FIE�DS �UST BE TYPED O� P�INTED. P�EASE NOTE: State �aw �equi�es an app�icant to comp�ete the �ive Scan/finge�p�int p�ocess fo� the pu�pose of conducting c�imina� histo�y �eco�d checks p�io� to �icensu�e. DATE OF BI�TH _________________________ SOCIA� SECU�ITY NO. _________________________ �o� Individua� Tax Identification Numbe�) 1.Check b�anch�es) in which you a�e app�ying fo� examination: B�anch 1 - The p�actice �e�ating to the cont�o� of househo�d and wood-dest�oying pests o� o�ganisms by fumigation with poisonous o� �etha� gases. B�anch 2 - The p�actice �e�ating to the cont�o� of househo�d pests exc�uding fumigation with poisonous o� �etha� gases. B�anch 3 - The p�actice �e�ating to the cont�o� of wood-dest�oying pests o� o�ganisms by the use of insecticides o� st�uctu�a� �epai�s and co��ections, exc�uding fumigation with poisonous o� �etha� gases. 2.Name of App�icant:��ast) �esidence Add�ess: City =ip Te�ephone Numbe�: ) Emai� add�ess: 4.�ai�ing Add�ess: �This add�essis whe�e the Candidate¶s Handbook wi�� be mai�ed.) City State =ip Emp�oyed by�Fi�m name) 6.Emp�oye�¶s Add�ess: City State =ip Te�ephone Numbe�: � ) 43E-1 ��ev. 0