Ill. Admin. Code tit. 8, § 220.ILLUSTRATION A – Application for Weed Control Superintendent Certification

STATE OF ILLINOIS

DEPARTMENT OF AGRICULTURE

Bureau of Environmental Programs

P.O. Box 19281

Springfield, Illinois 62794-9281

APPLICATION FOR WEED CONTROL SUPERINTENDENT CERTIFICATION

Please typewrite or print.

Name of Applicant

County in which you live

Telephone Number

Home Address

City

State

Zip Code

Business Name and Address

Telephone Number

Please list all the previous employment for the last five positions. (List most recent job first.)

Employer (Name and Address)

Date Started

Date Terminated

Reason for Leaving

Education

High School

Graduated

College

Graduated

Major

Minor

Other Advance Training

Additional Information:

I certify the above information to be true.

Signature

Date

Date Approved:

Approved:

Director

Illinois Department of Agriculture

(Source: Amended at 26 Ill. Reg. 14644, effective September 23, 2002)