Pesticide License add/transfer

APPLICATION TO ADD/TRANSFER PESTICIDE APPLICATOR LICENSE
DO NOT USE THIS FORM UNLESS YOU ARE ALREADY LICENSED.

Complete this form to transfer your Pesticide Applicator License to a different business or to add an additional license to your account. After the form is submitted NMDA will send an invoice for the transfer fee to the email address on the form.
I am:
Current License Information
Name
License Number
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
License Type
Supervising Commercial Applicator must sign to transfer a licensed Operator/Technician under his or her supervision. (Commercial Applicator information required if Operator/Technician selected above)
Commercial Applicator Name
License Number
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Signature of Commercial Applicator
New Business or Agency
Business Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Physical Address the same as Mailing Address?
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Date

MonthDayYear
Date
My signature affirms that all information provided here is true and correct to the best of my knowledge. It is a violation of the New Mexico Pesticide Control Act to provide false information on any application.
Signature of Licensee
Date

MonthDayYear
Date
Should be Empty: