Free Asbestos Certification Application - Individual, F-44017 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-44017 (Rev. 3/09) Page 1 of 2

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

ASBESTOS CERTIFICATION APPLICATION ­ INDIVIDUAL
Read instructions on page 2 before completing this form. Failure to complete all sections will delay processing.
Under sections 250.041 and 254.115, Wis. Stats., an individual must provide his or her Social Security Number to be certified. The Social Security Number (SSN) may be used to deny or revoke certification of persons delinquent in payment of taxes or child support and will not be available to the public. Personally identifiable 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 -- DHS Certification No.
Social Security No. Height ______Feet ______Inches State Zip+4 Weight

APPLICANT INFORMATION
Name (First, Middle, Last, including any suffix - Jr, Sr, III) Gender Female Mailing Address Telephone No. ( ) Company Name Mailing Address City Telephone No. ( ) Fax Telephone No. ( ) State Zip+4 Cellular Telephone No. ( ) Male City E-mail Address Birth Date (mm/dd/yy) minimum age 18

COMPANY INFORMATION (Employer, or business if self-employed)
DHS Asbestos Company No.

Cellular Telephone No. ( )

CERTIFICATION DISCIPLINE & FEES (Check the discipline and fee that applies) Discipline Fee Discipline Asbestos Inspector $175 Asbestos Worker Asbestos Management Planner $125 Exterior Asbestos Supervisor Asbestos Project Designer $175 Exterior Asbestos Worker Asbestos Supervisor $125 Replacement Card (Check Discipline) Make check or money order payable to DHS, or complete a credit card payment form. TRAINING (Most recent training must be in Wisconsin) Training Provider Training Course OTHER LICENSES, CERTIFICATIONS OR APPROVALS Within the past 5 years, did you have an asbestos license or certification issued by another state? If yes, provide the discipline(s) and issuing state. (attach additional sheet, if needed)

Fee $75 $75 $125 (one-time) $25

Training Dates (mm/dd/yy) Start: End: Yes No

ENFORCEMENT ACTIONS Within the past 5 years, did you have an asbestos license or certification denied, suspended or revoked by another state? Or, within the past 5 years, was action taken against you for a civil or criminal violation of statute, regulation or ordinance of the United States, this state, any other state, or any local government substantially related to asbestos activities or other environmental activities? Yes No If yes, what action was taken, why and by whom?

Note: You must completeand si n Page 2 g

For DHS use only Received Date

DWD Check

Paid Amount $

Deposit Date

F-44017

(Rev. 3/09) Page 2 of 2

Name of Applicant (First, Middle, Last)

ATTACHMENTS (Check that the following materials are submitted) Completed application form. Fee ­ check or money order payable to DHS, or completed credit card payment form ­ see instructions below for details. Training certificate(s), if needed ­ see instructions below for details. Completed asbestos company application form, if needed. COMPANY CERTIFICATION (Check most accurate response) Certified persons must work for or own a certified asbestos company before conducting regulated asbestos work. I currently work for or own a certified asbestos company or certified exterior asbestos company. I will work for a certified company when I do regulated work. An asbestos company or exterior asbestos company certification application is enclosed. AFFIDAVIT OF APPLICANT (Signature required) I state that I am the person referred to on this application and that all answers set forth are strictly true in each respect. I understand that false or forged statements made in connection with this application may be grounds for denying or revoking my certification or for other disciplinary or legal action. I also understand that if I am issued a certification card, failure to comply with the laws or rules of the State of Wisconsin may be cause for disciplinary or legal action. I affirm that I currently work for or own a certified asbestos company or certified exterior asbestos company, or that I will work for a certified company when conducting regulated work.

SIGNATURE ­ Applicant

Date Signed (mm/dd/yy)

SUBMITTING APPLICATION Application and payment forms are available online at http://dhs.wisconsin.gov/asbestos/Forms.htm or by calling (608) 261-6876. If mailing your application, use the mailing address listed below. If hand delivering or using overnight delivery service, use the street address. If paying by credit card, you may fax your application and attachments with a completed credit card form. Fax Telephone Number ­ (608) 266-9711 Mailing Address Department of Health Services Asbestos and Lead Section, Room 137 P.O. Box 2659 Madison WI 53701-2659 INSTRUCTIONS (Complete application neatly and accurately) Incomplete or unreadable applications may delay processing and an additional processing fee may be charged. CERTIFICATION Check the Initial box if applying for a discipline for the first time or after a lapse of more than 12 months since expiration. Check Renewal if applying before certification in the discipline has expired or within 12 months after expiration. APPLICANT INFORMATION ­ Provide the personal information requested, including your Social Security number, which is required by law. Provide the address where your certification card and renewal notice should be mailed. You are required to notify the Department when your mailing address changes. COMPANY INFORMATION ­ Provide the name of your employer, or if self-employed, the name under which you do business. To help us associate your information with the correct company, also provide the DHS asbestos company certification number. You must own, be employed by or under contract with a certified asbestos company before you may perform regulated asbestos abatement or management activities. CERTIFICATION DISCIPLINE & FEE ­ Place a check in the box for the discipline and fee amount to be paid. Enclose a check or money order payable to DHS or a completed credit card form, DPH 44029. The certification fee can not be refunded or prorated. DHS charges an additional fee for checks not honored by the bank. TRAINING ­ First-time applicants who have taken more than one class in the discipline must provide copies of all course completion certificates for the discipline (initial and refresher). You may have no more than a 24-month gap between any two courses taken. Your application will not be processed without your complete training history. Your most recent training for the discipline shall be in Wisconsin. The Wisconsin training provider will provide student training information directly to the Department so your paper training certificate will no longer be required with most applications. AFFIDAVIT OF APPLICANT ­ Read and personally sign the affidavit of your identity and accuracy of the information. Street Address Department of Health Services Asbestos and Lead Section 1 West Wilson Street, Room 137 Madison WI 53703