Commercial Structural Pest Control Business License Application

Structural Pest Control License Application

Commercial Business

Page 1 of 3

IOCI 18-191IL 482-0156 PCO Form 1984-5(9/17)

Printed by Authority of the State of Illinois

This application for a license as a commercial structural pest control business location must be submitted with the certificate of insurance

form and a $250 fee. The fee, made payable to the Illinois Department of Public Health, shall be in the form of a cashier’s check, money

order, or personal check and is non-refundable.

PRINT OR TYPE

Name of Business

Address of Business

City State ZIP Code County

Mailing Address (if different from above)

Business Telephone Number Federal Employer Identification Number

Type of Ownership (Check appropriate response)

Sole Proprietorship Corporation Other

(Specify)

Registered Agent (if a corporation, LLC, LP, LLP, LLLP)

Name

Address City State ZIP Code

Exact Name on file with IL Secretary of State

(Provide a copy of the certification on file with Illinois Secretary of State)

List of Officers, Partners, Members, Owners (To be completed by all types of ownership)

Name Home Address Title

Name of Certified Technician(s) Using Pesticides or Supervising Pesticide Applications for the above business location

(Use additional sheet if necessary.)

Name ID No. Signature

2 x 2 inch

Color Photograph

(Photocopies Not Accepted)

Name

2 x 2 inch

Color Photograph

(Photocopies Not Accepted)

Name

**Attach recent 2 x 2 inch head and shoulder color

photograph of manager/owner of this location. Print

name below each photograph. Photographs of

additional employees may be requested at a later date.

(Use additional sheet if necessary.)

052-

Structural Pest Control License Application

Commercial Business

Page 2 of 3

IOCI 18-191IL 482-0156 PCO Form 1984-5(9/17)

Printed by Authority of the State of Illinois

Type of Pest Control Activities Performed (Check appropriate areas)

General (Insect & Rodent)

Bird

Termites

Fumigation

Consultation

Inspection (Termite, etc.)

Retail Sales

Public or Multiple Housing

Food Mfg. & Processing

Wood Treatment

Other

(explain)

Have you previously operated a structural pest control business in this or any other state, or applied for an Illinois structural pest control

business license? (Check appropriate box(es))

Operated

Yes No

Applied

Yes No

If "Yes,” complete the following:

Business Name ID No. 051-

Business Address

City State ZIP Code

(a) Have you or any officer of this or any other business ever had a license for a structural pest control business denied, suspended or

revoked in Illinois or in any other state?

Yes

If "Yes," explain on a separate sheet of paper.

(b) Have you or any officers or employees of this or any other business ever had legal action initiated for violating pest control, pesticide

or deceptive business practice laws in Illinois, or any other state?

Yes No

If "Yes," explain on a separate sheet of paper.

Attach an Illinois Department of Public Health certificate of insurance form meeting the requirements of Section 9 of the Structural Pest

Control Act and Sections 830.250 and 830.260 of the Structural Pest Control Code to this application.

Will pesticides be stored (a) within 200 feet of any water well?

Yes No

(b) within 400 feet of a community water well system (municipal)?

Yes No

If you marked (a) or (b) "Yes," provide distance from storage to well:

If you marked (a) "Yes," have you notified the Illinois Environmental Protection Agency (IEPA) in writing per Section 14.2(b) of the

Environmental Protection Act (EPA), 415 ILCS 5/14.2(b), or obtained a waiver, exception, or certification of minimal hazard from IEPA per

Section 14.2(b), 14.2(c) or 14.5 of the EPA, 415 ILCS 5/14.2(b), 14.2(c) or 14.5?

Yes No

If "YES," attach a copy of the written IEPA notification, waiver, exception or certification of minimal hazard to this application.

I hereby certify that the information contained in this document is true and valid, and I understand that the Illinois Department of Public

Health may revoke any Illinois Structural Pest Control business license when the holder of such license knowingly makes false or

fraudulent claims.

Signature of Manager/Owner Date

Important Notice – this state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under

public act 79-578. Disclosure of this information is mandatory. This form has been approved by the forms management center.

Structural Pest Control License Application

Commercial Business

Page 3 of 3

IOCI 18-191IL 482-0156 PCO Form 1984-5(9/17)

Printed by Authority of the State of Illinois

Checklist for Completing Commercial Business Application

Applicant must —

1. Complete ALL spaces pertaining to the business (i.e. company name, address, etc.).

2. List mailing address if different from business locations.

3. List business telephone number including area code; list county

4. List Federal Employer Identification Number (none needed if owner is the only employee)

5. Mark type of ownership. If a corporation, limited liability company, limited partnership, limited liability limited partnership,

limited liability partnership, list registered agent’s name and address. List exact name of Illinois corporation, etc., on file with

the Illinois Secretary of State and provide a copy of that certification. (Out-of-state corporations must register with the Illinois

Secretary of State before completing the application).

6. List company officers. If a sole proprietorship, list owner. If a partnership, list partners. If an LLC, list members, etc.

7. Name of Illinois certified technician(s), including certification ID numbers and their signatures.

8. Attach a 2 x 2 inch photo and identify the manager(s) and/or owner(s) to the application.

9. Mark all types of pest control activities performed.

10. Answer all questions regarding former business licenses held or applied for.

11. Answer questions relating to this business or any other business in which you held an interest.

(Use additional sheet if necessary)

12. Attach a copy of the Department certificate of insurance form issued by an insurance company authorized to do business in

the State of Illinois (or by a risk retention or purchasing group formed pursuant to 15 U.S.C. Sec. 3901, et seq.) The certificate

must comply with Section 9 of the Structural Pest Control Act and Sections 830.250 and 830.260 of the Structural Pest Control

Code. A certificate form may be obtained from the Structural Pest Control web page at: www.dph.illinois.gov.

13. Answer questions regarding pesticide storage and attach a copy of the Illinois Environmental Protection Agency notification,

etc., if appropriate.

14. Sign and date the application.

15. Attach a $250 fee made payable to the Illinois Department of Public Health in the form of a personal check, cashier’s check or

money order.

If you have done all of the above, submit the application and your fee/payment to the address listed below:

Illinois Department of Public Health

Division of Environmental Health

Structural Pest Control Program

525 W. Jefferson St.

Springfield, IL 62761