Free 50746.pdf - Indiana

APPLICATION FOR DUPLICATE LEAD LICENSE
State Form 50746 (R4 / 2-08)

INDIANA STATE DEPARTMENT OF HEALTH INSTRUCTIONS: 1. This form must be used to apply for a duplicate lead license pursuant to 326 IAC 23. If accessing this form on-line, you may print the blank form and fill it out by hand; or you may fill it in on-line, then save it to your computer and print a hard copy for submission with original signatures.

INDIANA STATE DEPARTMENT OF HEALTH Lead and Healthy Homes Program 2 N Meridian St, 5 J Indianapolis, IN 46204 Phone: (317) 233-1250

http://www.in.gov/isdh/programs/lead/

2. No more than two (2) duplicate licenses will be issued to any one person in any calendar year. 3. Please type or print. 4. Return this completed form to the address provided in the upper-right hand corner of this page.

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PART A: GENERAL INFORMATION 1. Specify the discipline(s) for which you need a duplicate lead license(s): Inspector Project Supervisor Contractor Project Designer Worker Risk Assessor Clearance Examiner Applicant name Last

2.

First

Middle Initial

3.

Mailing address Street

City

State

ZIP code

4. 6.

Company name (if applicable): Date of birth
Day Year

5. 8. Height feet inches pounds 9. Weight 10. Eye color

Company telephone number: 11. Hair color

(

)

-

7.

Sex Male Female

Month

12. Home telephone number ( ) -

/

/

PART B: STATEMENT OF LOST OR STOLEN LICENSE 13. Please state the reason you are seeking a duplicate license. If you need more space than is available, please attach a second sheet to this application.

PART C:

SIGNATURE

I hereby certify that there are no misrepresentations in or falsifications of information submitted in this application. I understand that should investigations disclose any falsification of information submitted in this application, my license(s) may be revoked. I understand that failure to comply with requirements as outlined within federal, state, or local lead-related regulations may result in civil and/or criminal penalties.
SIGNATURE OF APPLICANT: ___________________________________________ DATE SIGNED: / /

PART D: SIGNATURE CARDS Applicant must sign both of the signature cards below. Application will be denied if the cards are not signed.

THIS LICENSE IS ISSUED FOR THE SOLE USE OF THE UNDERSIGNED AND IS NON-TRANSFERABLE. ANY USE OR POSSESSION, EXCEPT AS PRESCRIBED, IS PROHIBITED BY LAW. THIS LICENSE MUST BE IN THE POSSESSION OF THE UNDERSIGNED WHEN PERFORMING LEADRELATED ACTIVITIES AS PRESCRIBED BY 326 IAC 23.

THIS LICENSE IS ISSUED FOR THE SOLE USE OF THE UNDERSIGNED AND IS NON-TRANSFERABLE. ANY USE OR POSSESSION, EXCEPT AS PRESCRIBED, IS PROHIBITED BY LAW. THIS LICENSE MUST BE IN THE POSSESSION OF THE UNDERSIGNED WHEN PERFORMING LEADRELATED ACTIVITIES AS PRESCRIBED BY 326 IAC 23.

SIGNATURE

SIGNATURE