Free Asbestos Course Accreditation - Initial Application, F-00039 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Public Health F-00039 (03/09) Page 1 of 2

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

ASBESTOS COURSE ACCREDITATION ­ INITIAL APPLICATION
Complete all sections of the application and submit with fee and required course materials as listed below. Review Wisconsin Administrative Code Chapter DHS 159, Subchapter III, for a complete description of asbestos training course accreditation requirements. Under sections 254.115 and 250.041, Wis. Stats., a company must provide its Federal Employer Identification Number in order to be accredited. This information is used to deny or revoke certification of persons delinquent in payment of taxes or child support. Other information necessary for processing this application and collected on this form may be shared with other government agencies for compliance review and may be available to the public under an open records request.

COMPANY INFORMATION (Company must be a DHS certified Asbestos Company) Company Name Federal Employer Identification No. CONTACT INFORMATION Mailing Address City Records Street Address (If different from mailing address) City Training Location Address (If different from mailing address) City Office Telephone No. ( ) Course Contact Person Fax Telephone No. ( ) State Cellular Telephone No. ( ) E-mail Address Zip+4 Pager No. ( ) State Zip+4 State Zip+4 DHS Asbestos Company Certification No. (if issued)

COURSE DISCIPLINE AND FEE INFORMATION Check below the course discipline, applicable fees and total fee amount enclosed. The application fee and accreditation fee are payable upon application. Fees may be paid by check or money order made payable to DHS, or by credit card using the credit card payment form. Initial Course Asbestos Worker Course Asbestos Supervisor Course Asbestos Inspector Course Asbestos Management Planner Course Asbestos Project Designer Course Exterior Worker Course Exterior Supervisor Course Refresher Course Asbestos Worker Course Asbestos Supervisor Course Asbestos Inspector Course Asbestos Management Planner Course Asbestos Project Designer Course Exterior Supervisor Course Accreditation Fee $300 $300 $300 $300 $300 $300 $300 $150 $150 $150 $150 $150 $150

For DHS use only

Received Date

Amount Paid $

Deposit Date

F-00039 (Rev. 3/09) Page 2 of 2 Name of Training Provider COURSE APPLICATION MATERIALS Check each box to confirm the application package includes the following course materials and information. Index of submitted materials Training resources description Recordkeeping description Course registration plan Course agenda Student manual and materials Instructor manual and materials AFFIDAVIT OF APPLICANT (Signature required) I state that all the 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 course accreditation, company certification or individual certifications or approvals, or for taking other disciplinary or legal action. I also affirm that the training course named in this application meets the requirements of ch. DHS 159, Wis. Adm. Code, Subchapter III, Accreditation of Training Courses. Completed topic analysis worksheet Course test and answer key Course test blueprint Evaluation form Sample student training certificate Course approval letter(s) from other states/EPA, if any Asbestos company application, if not already certified

SIGNATURE ­ Owner or Designated Asbestos Coordinator

Date Signed (mm/dd/yy)

SUBMITTING APPLICATION Submit application, including completed application form, fees and required course materials, to DHS for review and approval. Forms, including company application form and credit card payment form, are available online at http://dhs.wisconsin.gov/asbestos/Forms.htm or by calling (608) 261-6876. If mailing the application, use the mailing address below. If hand delivering, use the street address. Mailing Address Department of Health Services Asbestos and Lead Section, Room 137 PO Box 2659 Madison WI 53701-2659 Street Address Department of Health Services Asbestos and Lead Section 1 West Wilson Street, Room 137 Madison WI 53703