Free Asbestos Certification Application - Company, F-44002 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-44002 (Rev. 4/09) Page 1 of 2

STATE OF WISCONSIN Bureau of Environmental and Occupational Health DHS 159, Wis. Adm. Code

ASBESTOS CERTIFICATION APPLICATION ­ COMPANY
(Please read instructions on page 2 before completing this form)
Under section 254.115, Wis. Stats., a company must provide its Federal Employer Identification Number (FEIN), or, if a sole proprietorship, the applicant's social security number (SSN), when applying for company certification. If the sole proprietor does not have a Social Security number, then a signed statement made under oath or affirmation that the applicant does not have a social security number is required. This information shall be used to deny or revoke company certification if certified by the Department of Revenue as delinquent in payment of taxes and will not be available to the public. Information necessary for processing this application and collected on this form, other than the SSN, may be shared with other government agencies for compliance review and may be available to the public under an open records request.

Applying for Initial certification Renewal certification Applying for Primary office Secondary office COMPANY CONTACT INFORMATION Please print
Company name

DHS company certification No.:

Federal Employer ID No. (FEIN), or sole proprietor's name & Social Security No. (SSN) Mailing address City Records street address City Telephone No. ( ) Cellular Telephone No. ( ) E-mail address State Fax Telephone No. ( ) Pager No. ( ) State

Tax status For Profit

Non-profit

Zip+4

Zip+4

COMPANY TYPE & CERTIFICATION FEE Enclose check or money order payable to DHS, or a completed credit card form.
Asbestos company ­ $400 Exterior asbestos company ­ $200 Fee exempt: Name WI state government Secondary office to a certified asbestos company ­ $200 Secondary office to a certified exterior asbestos company ­ $100 WI local government Title WI local education agency (K-12 public school) DHS Certification No.

AUTHORIZED COMPANY REPRESENTATIVE(S) Attach additional sheet if needed.

COMPANY ACTIVITIES Check all that apply.
Asbestos Abatement Contracting Asbestos Consulting Asbestos Training Construction / Renovation Contracting Demolition Contracting Flooring Government: Federal Local State Tribal Industrial / Manufacturing / Utility / Institutional / Commercial K-12 School Property / Building: Owner Management Roofing Siding University / College Other:

AFFIDAVIT OF APPLICANT Signature of an authorized company representative is required.
I state that I am an authorized representative of the company referred to on this application and that all the answers set forth are strictly true in each respect. I understand that false statements made in connection with this application may be grounds for denial or revocation of certification or other disciplinary or legal action. Neither this company, nor any owner, officer or authorized representative of this company has been cited for a violation of a federal, state or local asbestos regulation within the past three years ( except as described in the attached document).

SIGNATURE ­ Auth. Co. Rep.
For DHS use only Date Received

Title
DWD Check Completed Amount Paid $

Date Signed (mm/dd/yy)
Deposit Date

F-44002 (Rev. 4/09) Page 2 of 2 Company Name

CERTIFIED EMPLOYEES Attach additional sheet if needed.
Name Discipline DHS Certification No.

DHS COMPANY DIRECTORIES Check the public directories you would like your company listed in, if qualified:
Asbestos Abatement Contractor directory ­ must employ a certified asbestos supervisor Exterior Abatement Contractor directory ­ must employ a certified asbestos supervisor or exterior asbestos supervisor Asbestos Consultant directory ­ must employ a certified inspector, mgmt. planner, project designer, or supervisor (for air monitoring) Asbestos Training Provider directory ­ must have an accredited asbestos training course

INSTRUCTIONS Complete application neatly and accurately. If you have questions please call (608) 261-6876.
Incomplete or unreadable applications may delay processing and an additional processing fee may be charged. CERTIFICATION - Check the Initial box if applying for the first time or after a lapse of more than 12 months since expiration. Check Renewal if applying before certification expires or within 12 months after expiration. Check Primary if applying for only one office or the main office of a company. Check Satellite when applying for a secondary office to a certified primary office. COMPANY CONTACT INFORMATION ­ Provide all company information, including the FEIN, which is required by law. If your company is a sole proprietorship, your SSN may be used instead of a FEIN, or a signed statement made under oath or affirmation explaining that you do not have an SSN. You must provide a street address (not a PO Box) for the location where you store business records. CERTIFICATION FEE ­ Place a check in the box for the company type and fee amount to be paid. Enclose a check or money order payable to DHS or a completed credit card form, DPH 44029. The fee can not be refunded or prorated. DHS charges an additional fee for checks not honored by the bank. Fee Exemption: Your company is exempt from the certification fee if it is a unit of state or local government or a public or private not-for-profit K-12 school. Check the appropriate box. AUTHORIZED COMPANY REPRESENTATIVES ­ Provide the name, title, and DHS certification number (if certified) for each person authorized to act on behalf of the company. COMPANY ACTIVITIES ­ Check one or more activities that best represent the business of the company. AFFIDAVIT OF APPLICANT ­ An authorized representative of the company must review the application, then read and sign the affidavit. CERTIFIED EMPLOYEES ­ Provide the names, asbestos disciplines and DHS certification numbers for current employees who conduct regulated asbestos activities. PUBLIC COMPANY DIRECTORIES ­ DHS makes company contact lists available to the public upon request at 608-261-6876 and on the department website at www.dhs.wi.gov/asbestos. A company must be qualified to be listed in a directory. If you don't want to be listed on a public directory, leave this section blank.

SUBMIT APPLICATION
By mail to: Department of Health Services Asbestos and Lead Section, Room 137 PO Box 2659 Madison WI 53701-2659 By Fax to: 608-266-9711. Note: Submittal by fax is available only when accompanied by payment using Visa or MasterCard. The credit card form is available for download at http://dhs.wisconsin.gov/asbestos/Forms.htm or by calling 608-261-6876. Fax the application and credit card forms together. By hand delivery or delivery service to: Department of Health Services Asbestos and Lead Section 1 West Wilson Street, Room 137 Madison WI 53703