Technician Required Information Form

Please fill out all of the required fields below and submit the form.

Date: 2012-02-06
Technician Information
First Name:
Last Name:
Date of Birth: Year: - -
PIC Assignment Number: PIC-
Address:
City:
Postal Code:
Home Phone Number:
Fax:
Business/Consignee Information
Name:
Address:
City:
Postal Code:
Business Phone Number:
Fax:
Email Address:
PIC Test Information
Date Passed Academic: Year: - -
Grade: %
Number of Attempts to Pass Academic:
Examiner Name:
Licensed Exterminator #:
PIC Examiner Accreditation Number: PIC-E-
Date Passed Practical: Year: - -
Licensed Exterminator Name:
Licensed Exterminator #: