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