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Application for Broker Certificate

Author: Adrienne DeSchutter - Biosolid Education Coordinator/OMAFRA
Creation Date: 22 December 2005
Last Reviewed: 16 January 2008
The information contained in this document is derived from the Nutrient Management Act, 2002 and O. Reg 267/03 as amended. Every effort has been made to make it as accurate as possible, but is is not authoritative. Please refer to www.e-laws.gov.on.ca or the official volumes printed by Publications Ontario for the authoritative text of the act.

PDF - (135 kb)

Note: Original signatures are required. Please complete the application form and submit by mail or in person. Please Print Clearly in Ink.

Do Not Fax

Application for Broker Certificate

Section 1 - Company and Applicant Information

Company Name:______________________________________________________

Name of Owner:_______________________________________________________

Mailing Address (include 911, RR#): ______________________________________

City/Town: ___________________________ Postal Code: ___________________

County/Regional Municipality: ____________________________________________

Telephone: (       ) _______________________ Fax: (       ) ____________________

Email Address: _____________________________________________________

Name of Applicant or Name of Designated Authorized Agent: i.e. Name of person who completed the course and passed the exam (First, Middle, Last)

___________________________________________________________________

Section 2 – Requirements for Certification

  • Completion of Broker's Certificate Course OR Land Application Business Owner's Licence Course
  • Successful completion of exam

Course Date: ________________________________

Course Location: _____________________________

Exam Date: _________________________________

Exam Location: ______________________________

Grade Received: _________

checkbox I would like this Certificate issued in my name

checkbox I would like this Certificate issued in my company name, identifying me as the Designated Authorized Agent

Additional Information

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

checkbox 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.).

Applicant's Signature: __________________________________ Date: __________________________

CCA# :______________________________ if applicable

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 for: a) the support of certification and licensing requirements under the Nutrient Management Act, 2002, including future communications, plan approvals, monitoring and compliance, and b) will be added to an informational database. For information, contact the Manager, Training and Certification, Nutrient Management Branch, Ministry of Agriculture, Food and Rural Affairs, 519-826-6572. Note: In the future, the Certification and Registration registry may be maintained by a third party service provider.

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