5. I am applying to the Department to be placed upon the registry requiring prior notification of pesticide applications pursuant to Section 482.2267, Florida Statutes. Applicant's Signature Date
PART B (To be completed by the physician)
I, the undersigned physician, certify to the following:
1. I have examined the person making application above and have determined that his or her placement on the registry for prior notification of the application of the pesticide(s) or class of pesticides set forth below is necessary to protect that person's health.2. I [ ] am, [ ] am not, board certified and recognized by the American Board of Medical Specialties in one or more of the following medical specialties: [ ] Allergy
[ ] Toxicology
[ ] Occupational medicine
3. My license number is:.4. The distance surrounding the person's primary residence for which the person requires prior notification of the application of the pesticide(s) or class of pesticides set forth below in order to protect the person's health is: (Note: The distance specified shall be limited to those properties adjacent and contiguous to the person's primary residence unless the physician is board certified in one of the specialties specified in paragraph 2 above. In any event, the distance may not exceed a 1/2-mile radius of the boundaries of the property where the patient resides and must not exceed the minimum distance required to protect the applicant's health).
5. The pesticide(s) or class of pesticides for which I have determined that prior notification to the person of the application within the area indicated above is necessary to protect the person's health is (are): Signature of Certifying Physician Date
(Print name of Certifying Physician)