Registration Form For Lead Based Paint Third Party Examinations {50748}

REGISTRATION FOR LEAD-BASED PAINT THIRD-PARTY EXAMINATIONS State Form 50748 (R6 / 4-11) INDIANA STATE DEPARTMENT OF HEALTH INSTRUCTIONS: 1. 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. 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 2. 3. 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 third-party exam(s) for your license discipline from an EPA-approved 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. 4. 5. PART A: GENERAL INFORMATION 1. Applicant name First Mr. Ms. Home telephone number: Home address Street ( ) Last Middle initial 2. 4. 3. E-mail address: Apartment number City State ZIP code 5. 6. Company name (if applicable): Company telephone number: ( ) - 7. Company address Street Suite number City State ZIP code 8. 9. Fax number: ( ) PART B: TRAINING INFORMATION LIST THE DATES OF THE INITIAL TRAINING COURSE THE APPLICANT HAS COMPLETED FOR EACH DISCIPLINE: RISK ASSESSOR ­ Dates of training End Date: / / Start Date: / / End Date: / / / / INSPECTOR ­ Dates of training Start Date: PROJECT SUPERVISOR ­ Dates of training Start Date: / / End Date: / / PROJECT DESIGNER ­ Dates of training Start Date: / / End Date: / / (Continued on page 2) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 50748 (R6 / 4-11) Registration Form for Lead-Based Paint Third-Party Examinations 4/11 PART C: EXAMINATION INFORMATION 10. Check discipline for which you need to take the lead-based paint third-party examination (Reminder: Inspector license requires Inspector exam; Risk Assessor license requires Risk Assessor exam; 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/19124.htm 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/19124.htm 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: / / Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com