MTPlants

Request for Pesticide Course Recertification Credit Assignment

Complete this form to submit your pesticide education course for recertification credit approval at least 30 days prior to the course date.

Course Information

Type*:	!
Start Date of Course*: !	! ! !	Time*:	!
End Date of Course:	! ! !
Course Sponsor*:	!
Course Name*:	!
Course Location Name*:	!
This course is*:	!
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

First Name*:

Last Name*:

Address Line 1*:	!
Address Line 2:
City *:	!	State *:	!
Zip*:	! !	County:	!
Country *:	!

Phone1:

- -

Extension1:

Phone2:

- -

Extension2:

Fax:

- -

Email *:

Agenda

The agenda should include:
1.) Speaker(s) name(s), title and qualifications
2.) Presentation titles and description of each presentation
3.) Start and end time for each presentation
Note, the agenda can be copied into the window below or attached using the Files [Add] button that appears below after submitting the course.

Additional Note

Additional Information to display on website:

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 affirmation of fact. 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.