Free Asbestos Principal Instructor Application, F-00049 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-00049 (03/09) Page 1 of 2

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

ASBESTOS PRINCIPAL INSTRUCTOR APPLICATION
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 application, other than the SSN, may be shared with other government agencies as part of compliance review activities and may also be available under an open records request by the public.

Applying for

Initial Approval Renewal of Approval Social Security No. City Fax Telephone No. ( ) E-mail address State Zip + 4

APPLICANT INFORMATION Name (First, Middle, Last, including any suffix - Jr, Sr, III) Mailing Address Telephone No. ( ) Pager No. ( )

Cellular Telephone No. ( )

CERTIFICATIONS Check the disciplines in which you hold current certification and list expiration date for each. Provide certification number. Supervisor Exterior Supervisor Inspector Management Planner Project Designer QUALIFICATIONS Attach resume that describes all relevant professional training and work experience, including employers and dates. Reference Name Title Company Work relation to applicant Attach training certificate from a trainthe-trainer course with a minimum length of 16-hours, or equivalent training. Include course description or agenda or college transcript. Reference Name Title Company Work relation to applicant Provide three professional references or letters of recommendation, with no more than one from current employment. Reference Name Title Company Work relation to applicant Telephone Number ( ) Fee $50 $50 $50 $50 $50 Expiration Date Expiration Date Expiration Date Expiration Date Expiration Date DHS Certification No.

Telephone Number Telephone Number ( ) ( ) INSTRUCTOR DISCIPLINES & APPROVAL FEES (Check all that apply) Asbestos Discipline Inspector Management Planner Project Designer Supervisor Exterior Supervisor

Courses may teach Asbestos inspector initial and refresher Asbestos management planner initial and refresher Asbestos project designer initial and refresher Asbestos worker, supervisor, exterior supervisor initial and refresher, and exterior worker Exterior asbestos worker and exterior asbestos supervisor initial and refresher Total amount enclosed $
Entered into WALDO by

Make check or money order payable to DHS, or enclose credit card payment form.
For DHS use only Received Date DWD Check Paid Amount

Deposit Date

F-00049 (03/09) Page 2 of 2 Name of Applicant (First, Middle, Last) RENEWAL REQUIREMENTS (Complete this section if applying for renewal of approval) I am currently certified in the appropriate discipline(s) as indicated above. I attended at least one DHS training meeting within the past 4 years. Date of last meeting attended Within the past 12 months I taught one or more asbestos classes in each discipline for which I am requesting renewal. Last class taught in discipline Last class taught in discipline Last class taught in discipline Class Dates Class Dates Class Dates

Last class taught in discipline Class Dates OTHER LICENSES, CERTIFICATIONS OR APPROVALS Within the past 5 years, did you have an asbestos license, certification or approval issued by another state? Yes No If yes, which discipline(s) and who issued it?

ENFORCEMENT ACTIONS Within the past 5 years, did you have an asbestos license, certification or approval 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?

AFFIDAVIT OF APPLICANT I state that I am the person referred to on this application and 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 my certification or instructor approval or for other disciplinary or legal action. I also understand that if I am approved as a principal instructor, failure to comply with the laws or rules of the State of Wisconsin may be cause for disciplinary or legal action.

SIGNATURE ­ Applicant

Date Signed (mm/dd/yy)

ATTACHMENTS (Check the items being submitted with the application) Application Form ­ Complete, accurate and legible. Approval Fee ­ Check or money order payable to DHS, or completed credit card payment form. Resume with dates and locations of relevant training and experience. Train-the-Trainer training certificate and course description, or transcript from a college course. (Copy acceptable) Any supporting letters or recommendation or reference. SUBMITTING APPLICATION Application and credit card 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, use the street address provided below. If paying by credit card, you may fax your application and attachments with the completed credit card form. Return completed application to: Mailing Address Department of Health Services Asbestos and Lead Section, Rm 137 P.O. Box 2659 Madison WI 53701-2659 Fax Telephone Number ­ (608) 266-9711 Street Address Department of Health Services Asbestos and Lead Section 1 West Wilson Street, Room 137 Madison WI 53703