REVISION DATE: 12/17/2015
13
RESUME FORM
Individuals whom have two or more years of experience as a pesticide applicator in another state are also required
to pass the Massachusetts Applicator License (core) exam. They are NOT; however, required to wait the additional
two-years to upgrade their credential to one with certification categories. Such individuals should submit the below
resume form with their Commercial Certification Exam Application after they have received their Applicator License.
(PLEASE TYPE OR PRINT CLEARLY)
NAME: ____________________________________________________________________________
LAST FIRST MI
STREET ADDRESS: _________________________________________________________________
STREET APT #
____________________________________________________________________________________
CITY STATE ZIP
COMPANY/EMPLOYER: ____________________________________________________________
(If Any)
Signature ____________________________________________________________Date___________________
All of the information on this form is true and complete to the best of my knowledge
Please mark with a check [√] the one category you intend to become certified in:
Category
MA State Code Category MA State Code
Aerial
34
Mosquito and Biting Fly Control
47
Agriculture
33
Regulatory
48
Aquatic
39
Right of Way
40
Demonstration and Research
49
Shade Tree and Ornamental
36
Food Processing
50
TBT
54
Forest
35
Termite/Structural Pest Control
43
Fumigation
42
Turf
37
General Pest Control
41
Vertebrate Pest Control
44
General Public Health
46
Wood Preservative
52
License History
(Attach additional sheets if necessary)
List or write in the years and categories you have held a certification or license in Massachusetts or another state.
Years Certified/Licensed State(s) Categories of Certification
Education History
Name of College(s) or
Technical school(s) attended_______________________________________________________________
one year four year certificate program Other___________________________
Year graduated___________ Degree_________________ Major_________________
Please Enclose verification (i.e. copy of diploma, transcripts, etc.)
Additional educational credit may be given for seminars, short courses, correspondence courses, conferences or training meetings that
are pertinent to the category(ies) for which you are applying providing attendance is verified. Enclose copies of course descriptions and
Certificates of Attendance.
Pesticide Related Work History Experience
(Attach additional sheets if necessary)
Company/Employer _____________________________________Dates Employed_______________
Address___________________________________________________________________________
Supervisor’s Name and
Address__________________________________________________________________________
(if different from above)
________________________________________________________________________________
Licensed in Category(ies)_____________________________________________________________
Resume Templates 1210 Document(s)
