2018 Reciprocal Certification Request State of North Dakota

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Reynard Merritt
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2 2018 Reciprocal Certification Request State of North Dakota Personal Information Name Address Business Information Name of Business Address Phone Date of Birth State of Residence Phone Fax N.D. Pesticide Certification ID# Which address should we use for correspondence? q Personal q Employer Core status q Ground q Aerial Certification status q Applicator q Dealer q Consultant Do you work for a government agency? q Yes q No Is this certification for research and demonstration purposes? q Yes q No Certification Categories q AgPest q Home, Industrial & Institutional q Right of Way q Vertebrate q Fumigation q Ornamental & Turf q Seed Treatment q Wood Preservatives q Greenhouse q Public Health Certification Fees: Base fee (Ground or Aerial) $55 Number of categories x $10 = Appointment of agent Total $ $ $25 first time applying for N.D. reciprocity (one-time fee) Applicant Signature Date / / I attest that my certification has not been suspended or revoked in the past three years in any state or province. Method of Payment (payment must be included) Check # (payable to NDSU Extension Pesticide Program) To pay by credit card, go to: Proof of payment confirmation order # please attach copy of order receipt 10/2017 NDSU Extension Pesticide Program 205 Walster Hall NDSU Dept 7060 PO Box 6050 Fargo ND Phone or Fax County Commissions, North Dakota State University and U.S Department of Agriculture Cooperating NDSU is an equal EO/AA university Faxed or ed copies will not be accepted. Allow two to three weeks to process this request.

3 EXTENSION PESTICIDE PROGRAM 205 Walster Hall NDSU Dept 7060 PO Box 6050 Fargo ND or Fax County Commissions, North Dakota State University and U.S. Department of Agriculture Cooperating NDSU is an equal opportunity institution

4 Nonresident Appointment of Agent ID # FOR OFFICE USE ONLY NDSU Extension Pesticide Program Filing and recording fee $25 NDSU Extension Pesticide Program NDSU Dept 7060 PO Box 6050 Fargo ND Telephone North Dakota Century Code Nonresident application Designation of agent for service of process. Any nonresident applying for certifi cation as an applicator or dealer under this chapter to operate in this state shall fi le a written power of attorney designating the North Dakota State University Extension Service or its designee as the agent of such nonresident upon whom service of process may be had in the event of any suit against said nonresident person, and the power of attorney must be so prepared and in such form as to render effective the jurisdiction of the courts of this state over the nonresident applicant provided, however, that any nonresident who has a duly appointed resident agent upon whom process may be served as provided by law is not required to designate the extension service as such agent. The extension service is allowed such fees therefore as provided by law for designating resident agents. The nonresident must be furnished with a copy of the designation of the extension service or of a resident agent. The copy will be duly certifi ed by the North Dakota State University Extension Service. PLEASE PRINT 1. Name of Applicant Applying for Appointment Telephone # Complete Mailing Address City State Zip Code PLEASE PRINT 2. Business Name as Authorized to Transact Business in North Dakota Telephone # Complete Mailing Address City State Zip Code The undersigned does hereby APPOINT THE NORTH DAKOTA STATE UNIVERSITY, EXTENSION PESTICIDE PROGRAM as the true and lawful agent upon whom may be served all lawful process in any action or proceeding against the undersigned, and does hereby agree that any legal process served on said agent shall be of the same legal force and effect or validity as if served by myself, the partnership, or the corporation. State of Signature and Title of Applicant County of Subscribed and Sworn before me, this day of, 20. (Notary Seal) Notary Public My Commission Expires Certification of the NDSU Extension Pesticide Program FOR OFFICE USE ONLY I hereby certify that this instrument is a true and correct copy of non-resident appointment of agent fi led in the offi ce of the NDSU Extension Pesticide Program this day of, 20. Signature

7 Optional recording of Dicamba/Auxin Training for Engenia, FeXapan and XtendiMax herbicides used on Dicamba Tolerant Soybeans. The North Dakota Department of Agriculture will accept proof of participation in a Dicamba/Auxin Training as part of the conventional request for certification via reciprocity with North Dakota State University. Simply make a copy of your training receipt from the state or registrant and send it with your application for reciprocity certification. When we act upon your request for reciprocity and issue you a ND certification, we will update in our database that you completed the Dicamba/Auxin Training. You can check to see if this has been done by going to our verification search engine at: or on our home page at: January 23, 2018

[1] TWO [2] PASSPORT SIZE [2X2] PHOTOGRAPHS OF THE APPLICANT [NO SUBSTITUTES].

Auto Dealer License INFORMATION REQUIRED WITH THE NEW AND USED AUTO DEALER LICENSE APPLICATION [1] TWO [2] PASSPORT SIZE [2X2] PHOTOGRAPHS OF THE APPLICANT [NO SUBSTITUTES]. [2] ORIGINAL VALID DRIVER S