Update Contact Information Form

Please complete this form and click the “submit” button below to update your contact information with the ODA Pesticide Program. Please note this form is for all pesticide license holders, except commercial pesticide operators and pesticide dealers.

Full name of license holder (as it appears on your license) *
Oregon Pesticide License Number (if multiple, record only one here) *
Preferred communication language
English Español Other
If other language, list it here:
Date of birth (MM/DD/YY) (needed to confirm your identity) *
Do you wish to continue receiving a mailed copy of the pesticide newsletter?
No Yes
Mailing address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please make sure to fill out the ZIP code.
Physical/home address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please make sure to fill out the ZIP code.
Home phone - ### - ### ####
Cell phone - ### - ### ####
Direct email *