Free 49240.pdf - Indiana

APPLICATION FOR INDIVIDUAL LEAD LICENSE
State Form 49240 (R5 / 2-08) Approved by State Board of Accounts, 2008

INDIANA STATE DEPARTMENT OF HEALTH INSTRUCTIONS: 1.

Reset Form

This form must be used to apply for licenses 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. Please type or print in ink. Return this form, required addenda, and check or money order made payable to "ISDH Lead and Healthy Homes Program" by mail to: Cashier's Office Indiana State Department of Health PO Box 7236 Indianapolis, Indiana 46207

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/

APPLICATION TYPE Type of application (check one):

2. 3.

Initial license Renewal license

PART A: GENERAL INFORMATION - TO BE COMPLETED BY ALL APPLICANTS 1. Applicant name Last First Middle Initial

2. 3.

Home telephone number: (

)

City State ZIP code

Address where license should be mailed Street

4. 6.

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

5. 8. Height: feet inches

Company telephone number: 9. Weight: pounds 10. Eye color:

(

)

11. Hair color:

7.

Month

/

/

Sex: Male Female

PART B: PHOTOGRAPHIC IDENTIFICATION - APPLIES TO ALL APPLICANTS

Pursuant to 326 IAC 23-2-4(e) and 23-2-5(c), the applicant shall provide the Department two (2) copies of a clear and recent one and one-half inch (1-1/2") by one and one-half inch (1-1/2") identifying color photograph to be attached to the license. Please enclose your photographs with this application.

LEAVE THESE SPACES BLANK

FOR OFFICE USE ONLY

PART C: LICENSE RECIPROCITY ARE YOU APPLYING FOR INDIANA LEAD LICENSE(S) BASED ON LICENSE RECIPROCITY?: YES - Follow instructions below NO - Skip to Section D and complete the rest of application Persons applying for an Indiana lead license under license reciprocity (326 IAC 23-2-6.5) must do the following: Complete parts A, B, C, G, and I of this application. Attach to this application a legible copy of all current lead-based paint program licenses. If applicant is applying for Inspector, Risk Assessor, Project Designer, or Project Supervisor licenses, provide proof that applicant passed the appropriate third-party examination(s). Provide proof that applicant has attended an Indiana-approved Indiana Rules Awareness course. Pay the appropriate license application fee(s) outlined in Part G of this application.

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INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 49240 (R5 / 2-08)

Application for Individual Lead License 2/08

PART D: EDUCATION High School 12. High school name, city & state: 13. High school degree? No Yes - Date received: 14. GED Certificate / / No Yes - Date received: / /

PART E: WORK EXPERIENCE List below, beginning with your most recent job, only work experience that pertains to the license(s) for which you are applying. Additional sheets may be attached if necessary. A resume may be attached instead of completing this section.

WORK EXPERIENCE 1
Employer name: Employer address Street City Type of business or organization: Exact title of position: Name/title of immediate supervisor: Specific job duties (in detail): State ZIP code Employer telephone number: ( ) -

Dates employed FROM / TO / (Month / Year) (Month / Year)

Employment type Part-time Full-time

Number of hours/week

Number of employees you supervised

WORK EXPERIENCE 2
Employer name: Employer address Street City Type of business or organization: Exact title of position: Name/title of immediate supervisor: Specific job duties (in detail): State ZIP code Employer telephone number: ( ) -

Dates employed FROM / TO / (Month / Year) (Month / Year)

Employment type Part-time Full-time

Number of hours/week

Number of employees you supervised

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INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 49240 (R5 / 2-08)

Application for Individual Lead License 2/08

PART F: LEAD TRAINING INFORMATION Pursuant to 326 IAC 23, provide a copy of all required certificates of training indicating successful completion of approved initial course(s) and any requisite refresher training course(s).
· · Initial License: You must attach a copy of your initial training certificate and all refresher training certificates, if any, for every license for which you are applying. NOTE: If your training is not Indiana-approved, you must also attach a copy of your Indiana-approved Indiana Rules Awareness course certificate. Renewal License: You must attach a copy of your current refresher training certificate for every license for which you are applying.

If copies of all required training certificates are not attached, application will be denied pending submittal of the required documents. PART G: LICENSE FEES 15. Listed below is the annual license application fee schedule for each discipline. Check the appropriate box for each discipline for which you are applying and enter the total amount enclosed. Inspector Risk Assessor Project Supervisor Project Designer Worker $150 $150 $150 $150 $150
INSTRUCTIONS: Make all checks and money orders payable to "ISDH Lead and Healthy Homes Program". Per HEA 1725 (effective 5/3/99), local, city, county, and state government agencies are exempt from lead license fees. Pursuant to 326 IAC 23-2-8(c), the nonrefundable application fee is not: transferable from one (1) type of lead license to another, transferable from one (1) person to another, transferable to any other type of license issued by the department, unless requested by the applicant and approved by the department within three (3) days of submittal to the department or prior to application processing by the department, whichever is earlier.

Clearance Examiner $150

Total enclosed: $

PART H: REGISTRATION FOR LEAD-BASED PAINT THIRD-PARTY EXAM(S) If you have not already taken appropriate lead third-party exam(s) and you want to take the exam(s) in Indiana, please fill out the attached Indiana third-party exam registration form (State Form 50748) only when applying for an initial Inspector, Risk Assessor, Project Supervisor and/or Project Designer license(s) and only if you have already completed the requisite training courses. PART I: SIGNATURE IMPORTANT
· · · · · Allow two (2) to four (4) weeks for processing of a complete application package and receipt of your license(s). Make sure you have completed all appropriate sections of this application and have included all required addenda. Sign and date the application and return it to the Cashier address shown on page one (1) of this application. Applications will be returned which are incomplete or contain errors in response to any questions on the form and will result in a delay in processing and issuance of your license(s). All information requested on this application is mandatory for the administration and processing of your license application pursuant to 326 IAC 23. Except for scores on any training examination, all other personal data received will be regarded as a public record subject to disclosure in accordance with IC 5-14-3 and 326 IAC 17-1-4. Make sure you have enclosed two (2) 1-1/2 inch by 1-1/2 inch color photographs of the applicant. License(s) cannot be issued without photographs. Applicant must sign the two (2) signature cards below.

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: ___

/

/

____

SIGNATURE CARDS APPLICANT MUST SIGN 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. SIGNATURE

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

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