Chemical Handler Applicator Certification Form

Full Name

First NameLast Name

Email Address

example@example.com

Employer/Worksite Name

Worksite Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Types of Chemicals You Will Handle

Years of Experience Handling Chemicals

Training Completed

Certification Type Sought

Other

Have you ever been involved in a chemical handling incident?

If you answered yes to the previous question, please briefly describe the incident(s) and outcome. If not, enter 'N/A'.