Application For Asbestos Contractor License {52575}

APPLICATION FOR ASBESTOS CONTRACTOR LICENSE State Form 52575 (R3 / 2-15) Approved by State Board of Accounts, 2014 NOTE: This form must be used to apply for an asbestos contractor license pursuant to 326 IAC 18. If accessing this form on-line, you may print the form and fill it out by hand. Or you may fill it in on-line then save it to your computer. Submit a hard copy to IDEM through the U.S.Postal Service. Include any required documents and a one hundred fifty dollar ($150.00) check or money order made payable to "IDEM Asbestos Trust Fund" to the following address. Cashier ­ Mail Code 61-52 Indiana Department of Environmental Management 100 North Senate Avenue Indianapolis, Indiana 46204 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Office of Air Quality Asbestos Licensing Program 100 N. Senate Avenue, Room 1003 Indianapolis, IN 46204 Telephone: (317) 233-3861 asbnotify@idem.in.gov APPLICATION TYPE Initial license Renewal license PART A: GENERAL INFORMATION 1. Name of Company Owner or Designated Representative Last Name of Company Mailing Address of Company Street 4. E-mail Address of Company City State ZIP code First Middle Initial Telephone Number of Company ( 3. ) - 2. PART B: DESIGNATED REPRESENTATIVE PERSONAL AND TRAINING INFORMATION Pursuant to 326 IAC 18, an asbestos contractor applicant must have attended an Indiana-approved training course for asbestos project supervisor. A contractor may designate an employee who meets the training requirement. Personal information for the contractor or the designated employee is asked for below. An applicant is required to attach a copy of his or her most recent training certificate. NOTE: Any transfer of the designated representative status to another employee must be reported to the IDEM, by email or U.S. Postal Service within five (5) working days of the transfer. 5. Name of Designated Representative Last First Middle Initial 6. Date of Birth Month Day Year 7. Sex Male Female / 11. Hair Color 8. Height feet inches 9. Weight pounds / 10. Eye Color 12. Home Telephone Number ( ) - 13. E-mail Address American LegalNet, Inc. www.FormsWorkFlow.com 6820-120000-420000 Page 1 of 2 PART C: APPLICATION FEE INFORMATION 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. PART D: NOTES IMPORTANT d Allow a minimum of six (6) weeks for the processing of your application package and receipt of your asbestos contractor license. Make sure you have completed all appropriate sections of this application and have included all required documentation. Sign and date the application and return it to the Cashier address shown on page one (1) of this application. Applications that are incomplete or contain errors in response to any questions on the form will result in a delay in processing and issuance of your asbestos contractor license. All information requested on this application is MANDATORY for the administration and processing of your asbestos contractor license application pursuant to 326 IAC 18. Except for scores on any 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. PART E: CERTIFICATION AND 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 falsifications of information submitted in this application, my asbestos contractor license may be revoked. I have read Indiana's asbestos rules 326 IAC 18 and 326 IAC 14-10, and the U.S. Environmental Protection Agency's "Asbestos-Containing Materials in Schools Rule" and I understand the requirements of those rules. I understand that failure to comply with requirements as outlined within federal, state, or local asbestos-related regulations may result in civil and/or criminal penalties. SIGNATURE OF COMPANY OWNER: __________________________________________ DATE: SIGNATURE OF DESIGNATED REPRESENTATIVE: ____________________________________________ DATE: BOTH SIGNATURES ARE REQUIRED / / / / American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2