Application for Broker Certificate

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The information contained in this document is derived from the Nutrient Management Act, 2002 and O. Reg 267/03. Every effort has been made to make it as accurate as possible, but is not authoritative. Please refer to the e-Laws website or the official volumes printed by Publications Ontario for the authoritative text of the act.

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Note: Original signatures are required. Please type or print clearly in ink. Please complete the application form and submit by mail or in person. Do not fax. Signature and contact information are on page two.

PDF Version - 94 KB

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____ Application for new certificate

____ Application for renewed certificate

Current Certificate Number (if applicable): _________________________________

Section 1 – Applicant and Company Information

Applicant Name: _____________________________________________________

Mailing Address (include 911, RR#): _____________________________________

__________________________________________________________________

P.O. Box: __________________________________________________________

City/Town: _________________________________________________________

Province: __________________________________________________________

Postal Code: _______________________________________________________

Region/County: _____________________________________________________

Tel: _______________________________________________________________

Fax: _______________________________________________________________

E-mail: _____________________________________________________________

Company Name (for which you are an authorized agent, if applicable):

___________________________________________________________________

Company Contact: ____________________________________________________

Company Telephone: __________________________________________________

Company Fax: _______________________________________________________

* Note: You will need to notify OMAFRA in writing if you:

____ cease to be this company's authorized agent.

____ are hired by another company to be their authorized agent. You will also need to include company information.

____ have an ongoing day-to-day involvement/knowledge with the above company's brokering operation.

Section 2 – Requirements for Certification

Courses

____ Broker Certificate Course

Location: ___________________________________________________________

Date: ______________________________________________________________

Exam

Exam Date: _________________________________________________________

Exam Location: ______________________________________________________

Grade Received: _____________________________________________________

Additional Information

Personal information is collected under the authority of the Nutrient Management Act, 2002, s. 32. The information will be collected and used by the Ministry or their agents for: a) the support of the certification and licensing program under the Nutrient Management Act, 2002, including future communications, research, training, certification, program development, plan approvals, monitoring and compliance, and b) will be added to an informational database. For information, contact the Agricultural Information Contact Centre, Ministry of Agriculture, Food and Rural Affairs, 1-866-242-4460 or nman.omafra@ontario.ca. Note: In the future, the certification and registration registry may be maintained by a third party service provider.

____ Yes, I would like my name made publicly available through OMAFRA (e.g. OMAFRA website, regional distribution, written publications, information centre requests, etc).

____ Yes, I would like my company's name made publicly available through OMAFRA (e.g. OMAFRA website, regional distribution, written publications, information centre requests, etc).

Section 3 – Signature

Declaration

I hereby declare that, to the best of my knowledge, all information I have provided in this form is complete and accurate.  I further hereby declare that I have completed the training and testing requirements as required to obtain the Broker Certificate.

Name (print): ________________________________________________________

Applicant's Signature: _________________________________________________

Date: ______________________________________________________________

Applications must be submitted to:

Environmental Management Branch
Ministry of Agriculture, Food and Rural Affairs
Training, Education and Communications Unit
3rd Floor SW
1 Stone Road West
Guelph, Ontario N1G 4Y2
Tel: 1-866-242-4460