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Application For Individual Asbestos License 43786 - Indiana
| Application For Individual Asbestos License Form. This is a Indiana form and can be used in Air Department Of Enviromental Management Statewide . |
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APPLICATION FOR INDIVIDUAL ASBESTOS LICENSE State Form 43786 (R3 / 2-06) Approved by State Board of Accounts, 2006 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT IDEM Office of Air Quality Asbestos/Lead Program 100 N. Senate Avenue Indianapolis, IN 46204-2251 Phone: (317) 233-3861 or 1-888-574-8150 (Nationwide) http://www.in.gov/idem/permits/air NOTE: This form must be used to apply for licenses pursuant to 326 IAC 18. 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. Please type or print in ink. Return this form, required addenda, and check or money order made payable to "IDEM Asbestos Trust Fund" by mail to: APPLICATION TYPE Type of application (check one): Cashier Mail Code 50-10C Indiana Dept of Environmental Management 100 North Senate Avenue Indianapolis, Indiana 46204-2251 Initial license Renewal license PART A: GENERAL INFORMATION - TO BE COMPLETED BY ALL APPLICANTS 1. Applicant Name Last First Middle Initial 2. 4. Social Security # (optional): - City 3. Home Phone #: ( State ) ZIP code ( ) 11. Hair Color Address where license should be mailed Street Company name (if applicable): Birthdate Day Year 5. 6. Company phone #: 8. Height feet inches pounds 9. Weight 7. / Month Sex Male Female 10. Eye Color / PART B: PHOTOGRAPHIC IDENTIFICATION - APPLIES TO ALL APPLICANTS Pursuant to 326 IAC 18, 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: EDUCATION High School 12. High School Name, City & State: 13. High school degree? No Yes Date received: / _____________________________________ 14. GED Certificate / No Yes Date received: / / College If applicable to the license(s) for which you are applying, attach a copy of all pertinent college transcripts and/or diplomas. If this information is not attached, your application will be denied pending submittal of required documents. 6820-120000-420000 Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 43786 (R3 / 2-06) Application for Individual Asbestos License PART D: 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, or resumes may be attached. Licenses that require work experience (Project Supervisor, Project Designer, Management Planner) will be denied if work experience information is not provided. 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 phone #: ( ) - Dates employed (month/year) FROM / TO / Employment type Part-time Full-time # Hours/week # 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 phone #: ( ) - Dates employed (month/year) FROM / TO / Employment type Part-time Full-time # Hours/week # Employees you supervised PART E: ASBESTOS TRAINING INFORMATION Pursuant to 326 IAC 18, provide a copy of all required certificates of training indicating successful completion of Indiana-approved initial course(s) and any requisite refresher training course(s). · · Initial License: You must attach a copy of your Indiana-approved initial training certificate and all Indiana-approved refresher training certificates, if any, for every license for which you are applying. Renewal License: You must attach a copy of your current Indiana-approved 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. Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 43786 (R3 / 2-06) Application for Individual Asbestos License PART F: LICENSE FEES 15. Listed below is the annual license application fee schedule for each asbestos license discipline. Check the appropriate box for each discipline for which you are applying and enter the total amount enclosed. Note: Inspector Management Planner Project Designer Project Supervisor Worker $100 $100 $100 $100 $50 Make all checks and money orders payable to "IDEM Asbestos Trust Fund". Pursuant to 326 IAC 18, the nonrefundable application fee is not: transferable from one (1) type of asbestos 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. Total enclosed: $ PART G: NOTES IMPORTANT · · · · · Allow a minimum of four (4) weeks for processing of a complete application package and receipt of your license(s). Applicants must complete all appropriate sections of this application and must include 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 18. 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. Applicants must enclose two (2) 1-1/2 inch by 1-1/2 inch recent color photographs of themselves. License(s) cannot be issued without photographs. Applicants must sign the two (2) signature cards at the bottom of this page. PART H: CERTIFICATION AND SIGNATURE I hereby cert
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