Free 50748.pdf - Indiana

REGISTRATION FOR LEAD-BASED PAINT THIRDPARTY EXAMINATIONS
State Form 50748 (R4 / 2-08)

INDIANA STATE DEPARTMENT OF HEALTH
INSTRUCTIONS: 1.

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INDIANA STATE DEPARTMENT OF HEALTH Lead and Healthy Homes Program
2 N Meridian St, 5 J Indianapolis, IN 46204

Please type or print in ink. 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, and then save it to your computer and print a hard copy for submission with original signatures. Fill out this form only if you are applying for INITIAL lead license(s) and only if you want to take the third-party exam(s) in Indiana. (If you have already taken the thirdparty exam(s) for your license discipline from an EPAapproved state or tribe lead program, you do not have to take the exam(s) again unless the item listed next applies to your situation.) If you have allowed more than forty-eight (48) months to lapse since your last training course(s), you will have to take initial training course(s) again and also take the third-party exam(s) again. If you are renewing lead license(s), this form is not necessary unless you have a lapse in training as stated in the previous item above.

Phone: (317) 233-1250
http://www.in.gov/isdh/programs/lead/

2.

Return this completed registration form by MAIL to: ISDH Lead and Healthy Homes Program Attn: Exam Coordinator Indiana State Department of Health 2 N Meridian St, 5 J Indianapolis, Indiana 46204 or by FAX to: Lead Exam Coordinator (317)-233-1630

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PART A: GENERAL INFORMATION

1. Applicant name
Mr. Ms. First Last Middle initial

2. Home telephone number: 3. Home address
Street

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Apartment number

City

State

ZIP code

4. Company name (if applicable): 5. Company telephone number: 6. Company address
Street Suite number ( ) -

City

State

ZIP code

7. Fax number:

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PART B: TRAINING INFORMATION

8. LIST THE DATES OF THE INITIAL TRAINING COURSE THE APPLICANT HAS COMPLETED FOR EACH DISCIPLINE:
INSPECTOR ­ Dates of training Start Date: / / End Date: / / RISK ASSESSOR ­ Dates of training Start Date: / / End Date: / /

PROJECT SUPERVISOR ­ Dates of training Start Date: / / End Date: / /

PROJECT DESIGNER ­ Dates of training Start Date: / / End Date: / /

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INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 50748 (R4 / 2-08)

Registration Form for Lead-Based Paint Third-Party Examinations 2/08

PART C: EXAMINATION INFORMATION 10. Check every discipline for which you need to take the lead-based paint third-party examination

(Reminder: Inspector license requires Inspector exam; Risk Assessor license requires Inspector and Risk Assessor exams; Designer and Supervisor licenses require Supervisor exam.):
Inspector Risk Assessor Project Supervisor

Examinations are free and may be taken in Indianapolis at the Indiana State Department of Health. Please see the ISDH Lead and Healthy Homes Program website at http://www.in.gov/isdh/programs/lead/ to find the list of available dates (examinations are usually offered twice a month on Mondays).

INDIANAPOLIS EXAM SITE: (see http://www.in.gov/isdh/programs/lead/ for scheduled dates and times) 1st choice of Indianapolis date: / / 2nd choice of Indianapolis date: / /

Time: 10:00 A.M. [Indianapolis time]

Time: 10:00 A.M. [Indianapolis time]

Your registration will be confirmed by mail or fax to confirm the date, time, and location of all exams for which you have registered. Check below where you prefer your confirmation letter to be sent and/or faxed: Home Address Company Address Fax to fax number listed for Item #7 on page 1 of this application

REGISTRANT'S SIGNATURE:
(Exam will not be scheduled unless signed by registrant.)

_____________________________________

DATE SIGNED:

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