Free Asbestos Course Accreditation - Renewal Application, F-00040 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Public Health F-00040 (3/09) Page 1 of 1

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

ASBESTOS COURSE ACCREDITATION ­ RENEWAL APPLICATION
Complete all sections of this application and submit with fee and any revised course materials. 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 on payment of taxes or child support. Personally identifiable 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. Renewal for: Company Name Contingent Accreditation (may only renew twice) Full Accreditation DHS Company No.

COMPANY INFORMATION

CONTACT INFORMATION (Complete for any information that has changed since the last application)
Mailing Address City Records Street Address City Training Location Address (If different from mailing address) City Office Telephone No. ( ) Course Contact Person Fax Telephone No. ( ) State Cell Telephone No. ( ) E-mail Address Zip+4 Pager No. ( ) State Zip+4 State Zip+4

COURSE AND ACCREDITATION FEE
Check the course included in the application. The accreditation fee is payable upon application. Fees may be paid by check or money order payable to DHS, or by credit card using the Credit Card Payment form, DPH 44029. Initial Course Fee Refresher Course Fee Asbestos Supervisor Course $300 Asbestos Supervisor Course $150 Asbestos Worker Course $300 Asbestos Worker Course $150 Asbestos Inspector Course $300 Asbestos Inspector Course $150 Asbestos Management Planner Course $300 Asbestos Management Planner Course $150 Asbestos Project Designer Course $300 Asbestos Project Designer Course $150 Exterior Supervisor Course $300 Exterior Supervisor Course $150 Exterior Worker Course $300

REVISED COURSE MATERIALS (Submit copies of all course revisions made since the last accreditation approval)
Revisions (Check all that apply) Course agenda Student manual and materials Instructor manual and materials Course test, answer key or blueprint Evaluation form Student training certificate

AFFIDAVIT OF APPLICANT
I state that 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 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. SIGNATURE ­ Owner or Designated Asbestos Coordinator Date Signed (mm/dd/yy)

SUBMITTING APPLICATION
If mailing application, use the mailing address below. If hand delivering, use the street address. If paying by credit card, you may fax the application, revised materials and credit card form to (608) 266-9711. The credit card payment form is available online at http://dhs.wisconsin.gov/asbestos/Forms.htm or by calling (608) 261-6876. Mailing Address Department of Health Services Asbestos and Lead Section Room 137 PO Box 2659 Madison WI 53701-2659 For DHS use only Received Date Street Address Department of Health Services Asbestos and Lead Section 1 West Wilson Street, Room 137 Madison WI 53703 Amount Paid $ Deposit Date