317937 10/31/17 v, CITY OF CARMEL, INDIANA VENDOR: 371293
ONE CIVIC SQUARE INDIANA STATE CHEMIST CHECK AMOUNT: $'""""*"*45.00`
CARMEL, INDIANA 46032 INDIANA STATE CHEMIST PURDUE UNIV. CHECK NUMBER: 317937
175 S.UNIVERSITY ST. CHECK DATE: 10/31/17
WEST LAFEYETTE IN 47907-2063
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 RENEW2018 45.00 ORGANIZATION & MEMBER
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Page 1
2018 INDIANA PESTICIDE COMMERCIAL APPLICATOR RENEWAL APPLICATION
BROOKSHIRE GOLF CLUB
12120 BROOKSHIRE PARKWAY
CARMEL IN 46033-1212 Current Phone: (317)846-7431 Ext.
Current Fax:
Business e-mail: bhiggins@carmel.in.gov
Submit the Renewal Application in the enclosed envelope before December 31,2017.Those
applications postmarked after December 31,by law,require an additional 100%late fee penalty.
NOTE: Certification in each category is valid for a five(5)year period.
A license and technician registration is renewed each year prior to Decemb
License Number= N35567 FEE-$45.00 RENEW DO NOT RENEW
ROBERT DAVID HIGGINS Personal e-mail:bhiggins@carmel.in.
Category 3A 3 CCHs earned out of 15 required Category Expires 12/31/2020
Category 3B 0 CCHs earned out of 20 required Category Expires 12/31/2022
[Total Fee Due:$45.00
Submit the Renewal Application in the enclosed envelope before December 31,2017.Those
applications postmarked after December 31,by law,require an additional 100%late fee penalty.
Send to: Office of Indiana State Chemist,Purdue University, 175 S.University St.,West Lafayette,IN 47907-2063
Make check payable: Indiana State Chemist
I hereby swear and affirm that the list being submitted is a true and accurate record of the current certified employees working
at this business location.I also acknowledge that failure to provide accurate information on this application
form constitutes a violation of the Indiana Pesticide Use and Application Law(IC 15.3-3.6 Section 65(11)).
Printed Name Job title of person signing
/0 _d--- /� --- --
Signature Date
**** FOR STATE CHEMIST OFFICE USE ONLY ****
APPROVED DATE
Check No Amount Entered Under
License# GN30022 Posted Account#
RT PAL
FAL Amount
otal Fee Due:$45.00