NCS000416_2022 Karl K Pesticide Renewal Lic_20230912

NORTH CAROLINA DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES
STRE COMMISSIONER
APPLICATION FOR LICENSE/CERTIFICATE RENEWAL
2022
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FILE NUMBER 9428 Public Operators -County & Municipal 12131I2022
EXPIRATION DATE
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LICENSEE: 032 9428 USE SPACE BELOW TO MAKE ANY NECESSARY k
CORRECTIONS OR UPDATES
KEEFE, KARL B.
102 TOWN HALL DRIVE
LELAND NC 28461
PHONE: [phone]
EMAIL: [e-mail]
COUNTY: BRUNSWICK
INSTRUCTIONS: Please examine this form carefully,and,if there are any changes to
be made,print them in the corresponding blanks on the right-hand side. Sign at the
bottom,enclose any required fee,and mail to:
NCDA&CS Questions? Please contact us at: [phone]
Structural Pest Control and Pesticides Div.
1090 Mail Service Center No application is accepted unless signed by the licensee and
Raleigh, NC 27699-1090 accompanied by full payment. Make payable to NCDA.
Subclassification: B E
**RETURN THIS ENTIRE FORM. DO NOT DETACH**
FOR OFFICIAL USE ONLY.
Prior Lic.Expired: 12/31/2021 Certification Expires: 06/30/2026
Original Issue: 09/08/2021
Lic Type: 032 •Sort by Last Name:
FNum: 9428 KEE
Form Printed on: 09/20/2021
'*DO NOT D�.TAg f_'__
SI 0F�an nE REQUIRED .This is your Only notice
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APPLICANT'S SIGNATURE There Is no fee for this renewal
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Credits for Recertification must be earned prior to
06130/2026. ,
For training opportunities,contact your local '..
Cooperative Extension or visit our website
w .ncagr.gov/spcap/pesticides
On reverse side, please list Name,Address,and
Phone Number of individivals who currently apply
pesticides under your supervision.
CHECK YOUR CREDIT STATUS ONLINE AT IIII IIIII IIIII IIII(IIIII IIIII IIIII I(IIIII IIII
WWW.NCAGR.GOV/SPCAP/PESTICIDES
032 9428