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PESTICIDE REGISTRATION—CLOSED BOOK EXAMS

Please check desired exam(s)/category(s)

To qualify for Pesticide Certification you must successfully complete the Pesticide Core exam and one other category exam.

☐ PEST-0101 Pesticide Core (required)*NEW Manual & Exam 2012-13 ☐

☐ PEST-0102 Aerial *NEW Manual & Exam 2013-14

PEST-0013 Livestock Products☐ PEST-0030 Agriculture Ground *NEW Manual & Exam 2013-14 ☐

PEST-0010 Mosquito *NEW Manual & Exam 2014-15☐ PEST-0004 Forestry ☐

PEST-0011 Rural Municipal *NEW Manual & Exam 2016-17☐ PEST-0032 Fumigation/Stored Ag ☐

☐

☐ PEST-0006 Industrial *NEW Manual & Exam 2019-20 ☐ PEST-0031 Structural

TOTAL: $0.00

PEST-0033 Greenhouse

Registration and payment must be received 10 business days prior to exam date

Please check desired exam location/date. ** Alternate location or date needs pre-approval with an additional fee of $100 per exam (see below).

Winnipeg Border Place Plaza

Unit #371313 Border St.

Exams begin at9 a.m.

Dauphin Parkland Campus

520 Whitmore Avenue E

Exams begin at

9 a.m.

Russell ☐MB Ag GO Office434 Main St North

The Pas ☐ M B Ag GO Office

236-3rd St & Ross Ave

☐ Swan RiverMB Ag Go Office

☐ SomersetM B Ag GO Office

279 Carlton St

Please ensure chosen location (above) is checked.

☐ Dec. 06, 2019 ☐ Dec. 18, 2019 - Rm 515 ☐ Dec. 18, 2019

Exams begin at 9:00 a.m.

for ALL GO Officelocations.

☐ Dec. 18, 2019

☐ Jan. 15, 2020 ☐ Jan. 20, 2020 - Rm 515 ☐ Jan. 20, 2020 ☐ Jan. 20, 2020

☐ ☐ Feb. 19, 2020 - GYM ☐ Feb. 19, 2020 ☐ Feb. 19, 2020

☐ ☐ Mar. 18, 2020 - GYM ☐ Mar. 18, 2020

☐

☐

Apr. 15, 2020 - GYM ☐ Apr. 15, 2020 ☐ Apr. 15, 2020☐Apr. 24, 2020

☐ May 13, 2020 - Rm 515 ☐ May 13, 2020 ☐ May 13, 2020

☐

May 06, 2020

☐ June 16, 2020 - Rm 515 ☐ June 16, 2020 ☐ June 16, 2020

x TOTAL

APPROVED: ☐ Date: Time:

**Please note: If an alternate date/location is used, ACC is not liable for any lost exams through courier service.

Please contact the ACC Bookstore directly at 1.800.862.6307 Ext. 6788 to purchase your course manual(s).

STUDENT INFORMATION (fields marked with * are required)

Student Number (if you have attended ACC before) Gender (M or F)

☐M ☐ F

Last Name * First Name * Middle Initial * Birth date (yyyy/mm/dd) *

Home Mailing Address * City * Prov. * Postal Code *

Home Phone * Business Phone Cell Phone PERSONAL Email*

Exam Registration 2019-20

Pesticide Certificationswww.assiniboine.net/pesticide

PER Exam X # of Exams

☐ May 27, 2020

Winnipeg Canadian Mennonite

University (CMU) 600 Shaftesbury Blvd

SOUTH CAMPUS CONFERENCE ROOM

Exams begin at9 a.m.

Mar. 18, 2020

☐

☐

Brandon ACC

1430 Victoria Avenue East

Exams begin at 1 p.m.

PEST-0140 Landscape/Golf Course *NEW Manual & Exam 2015-16

*Note: ONE person per Golf Course or Landscape Co. needs IPM

Social Insurance # (SIN) *

☐

Feb. 05, 2020

Mar. 04, 2020

Apr. 01, 2020

June 10, 2020

**ALTERNATE LOCATION/DATE: Contact 204.725.8700 ext 6716 to arrange pre-approved alternate location/date.

Alternate Location (within Canada)/Date Fee (non-refundable) + $125 Exam Fee = $200.00 P per Exam

PEST-0008 Seed Treatment *NEW Manual & Exam 2017-18

☐ June 24, 2020

Mar. 25, 2020

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DECLARATION

I understand the grade I receive on my exam may be disclosed confidentially with my sponsor and Manitoba Ag’s Licensing Agent.

I declare that I have read and understood the information on this registration, including the Notice Regarding Collection, Use and Disclosure of Personal Information and that all statements made with respect to this registration are true and complete. I understand that misrepresentation, falsification of documents or the withholding of requested information with respect to this application can result in cancellation of the registration or dismissal from the college. I accept that any information on falsified documents may be shared with the Association of Registrars of the Universities and Colleges of Canada. By entering my signature, I agree to comply with the regulations of Assiniboine Community College.

By checking this box, I agree to the "Declaration" terms

Page 2 of 2 Revision date: July 2014

PAYMENT OPTIONS Visa MasterCard Cheque/Money Order (payable to Assiniboine Community College)

Card # Expiry Date Cardholder Phone #

Card Holder Name

Sponsorship authorization gives the college permission to invoice/provide receipt in the Company name for the above named student. Before final grade reports can be released, payment must be received from the Sponsor.

Company Name Telephone Fax

Company Address City Province Postal Code

Contact Name

*Sponsors please note that if you do not complete the sponsorship sectionthe receipt will be made in the student’s name and mailed directly to the student.

For internal use only: Reg Accts Ag Ext

Click here to submit form

Assiniboine Community College’s collection, use and sharing of personal information is set out in its Privacy Policy and a copy of it is available by request from the FIPPA/PHIA Coordinator. By submitting your application or registration to Assiniboine you confirm that you consent to the collection and use of your personal information as identified at www.assiniboine.net/privacy