Registration Form

Registration Form
To complete this form on your computer you must first download it. Alternately, you may print the form, fill it out, and send it by
email attachment, fax, or by letter mail. The contact information is found at the bottom of this form.
Personal information (please print)
I already have a SOFAD file number:
daymonth
year
Date of birth M W
Sex
Last name
First name
Number
Street
Apt. No. or P.O. Box
City
Province
Postal code
Québec
Other :
Home telephone No.
Telephone No. at work
Area code
Area code
Number
Email
Number
Registration for an examination or a course (includes the examination)
Please indicate the examinations or courses for which you wish to register.
Exam
Course Examination or course title
Price
IN
Common
Sale
Use
Examination
Tronc
Utilisation
Vente
Examen
ENENGLISH
of
FRANÇAIS
des
commun
Pesticides
à Core
l'intention
pesticides
desfor
pesticides
for
pour
workers
– Pesticide
in
Aerial
Application
Cultivated
Retail
Wholesale
Agriculture
–des
les
Vente
utilisateurs
préposés
–who
en
Sales
Application
Application
milieu
Users
au
en
Lands
(classes
apply
(Class
by
for
in
on
détail
gros
Buildings
Ornemental
attitrés
Fumigation
Raw
Extermination
the
agricole
pesticides
de
(classes
4),
(classe
1Control
pesticides
en
par
pour
sur
Lands
toPart
àterrain
bâtiment
horticulture
5)
les
aéronef
fumigation
l'application
for
1le
extermination
4),
and
Iterres
II
àto
Horticulture
contrôle
of
Horticultural
5)
Partie
lawns
Retail
Stinging
inculte
etàcultivées
au
des
Iornementale
II
Sales
des
détail
defins
Insects
pesticides
insectes
(classes
Purposes
horticoles
(classes
piqueurs
1sur
1toàles
3) pelouses
IN
Common
Sale
Use
Examination
Tronc
Utilisation
Vente
Examen
ENENGLISH
of
FRANÇAIS
des
commun
Pesticides
à Core
l'intention
pesticides
desfor
pesticides
for
pour
workers
– Pesticide
in
Aerial
Application
Cultivated
Retail
Wholesale
Agriculture
–des
les
Vente
utilisateurs
préposés
–who
en
Sales
Application
Application
milieu
Users
au
en
Lands
(classes
apply
(Class
by
for
in
on
détail
gros
Buildings
Ornemental
attitrés
Fumigation
Raw
Extermination
the
agricole
pesticides
de
(classes
4),
(classe
1Control
pesticides
en
par
pour
sur
Lands
toPart
àterrain
bâtiment
horticulture
5)
les
aéronef
fumigation
l'application
for
1le
extermination
4),
and
Iterres
II
àto
Horticulture
contrôle
of
Horticultural
5)
Partie
lawns
Retail
Stinging
inculte
etàcultivées
au
des
Iornementale
II
Sales
des
détail
defins
Insects
pesticides
insectes
(classes
Purposes
horticoles
(classes
piqueurs
1sur
1toàles
3) pelouses
Note: As soon as SOFAD receives payment for an examination or a course, it is authorized to transmit the information in this form and
the results of the examination to the Ministère du Développement durable, de l’Environnement et de la Lutte contre les changements
climatiques.
Method of payment
Sub-total
Credit card:
Visa
MasterCard
monthyear
GST
No: PST
No: 141227892 RT
Expiration date:
You can also send this form making sure to enclose, if appropriate, a cheque or money order.
Attached:
money order
cheque
Payable to SOFAD
Customer Service
SOFAD
2200, Sainte-Catherine Street East, Montreal, Quebec H2K 2J1
Telephone No.: 514 529-2801 or 1 866 840-9346 – Fax No.: 514 529-4788
Email: [email protected]
No: 1018814907
Total cost
A receipt will be issued.
If you are paying by check there will be an additional 10-business day delay in processing your
file from the time the check is received.
Once you have duly completed this form,
please send it to the address noted below or by email or fax.
Note: Fees associated with
courses, course materials,
and examinations are not
refundable.
I confirm that the information provided above is
proof of my examinationand/or course registration with SOFAD.
(2016-10-04)