Registration Form for CEU Hours

Name:__________________________________

Address_________________________________

City____________________________________

State____________________________________

Zip_____________________________________

Phone # (        ) ___________________________
E-Mail (optional)__________________________  

Enter Your Arizona License Numbers Below.
Private Applicator #________________________
Commercial Applicator #____________________
Pest Control Advisor #______________________
Enter Your California License Numbers Below.
Private Applicator #__________________
Ground Applicator (QC) #__________________
Ground Applicator (QL) #_______________
Aerial Applicator (AP/JP) #_________________
Pest Control Advisor(AA) #__________________

Signature___________________________________________Date__________________
For more information or assistance call:
Tim Braun: Home (928) 726-8958 Robert Braun (928) 580-7801
Email tbraun783@aol.com
(Check Exams Taken)

For (   ) Arizona (   ) California
(  )   Citrus Scarring Pest Control
(  )   Citrus Weed Control
(  )   Citrus Armored Scale and
Mealy Bug Control
(  )  Spinach Pesticide Application
(  )  Spinach Post Emergence Pest Control
(  )  Spinach Pre Emeergence Pest Control