Application For Duplicate Asbestos License {48740}

APPLICATION FOR DUPLICATE ASBESTOS LICENSE State Form 48740 (R3 / 10-13) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This form must be used to apply for a duplicate asbestos license 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. more than two (2) duplicate licenses will be issued to any one person in any calendar year. No You may submit your completed application along with a picture ID copy to the Indiana Asbestos Licensing Program either by email to asbnotify@idem.in.gov, through the US Postal Service using the mailing address listed above or fax the application and picture ID copy to (317) 233-3257. IDEM ­ Office of Air Quality Asbestos Program 100 N. Senate Avenue Rm. 1003 Indianapolis, IN 46204-2251 Telephone: (317) 233-3861 Fax: (317) 233-3257 Email: www.asbnotify@idem.in.gov PART A: GENERAL INFORMATION 1. Specify the discipline(s) for which you need a duplicate asbestos license(s): Inspector Management Planner 2. Applicant Name Last Project Supervisor Worker Project Designer Contractor First Middle Initial 3. Address to which license should be mailed: Street City State ZIP code 4. Company Name (if applicable) 5. ( Company telephone number ) 11. Hair Color 12. Home telephone number 6. Birth Date Month Day Year / / 7. Sex Male Female 8. Height feet inches 9. Weight 10. Eye Color pounds ( ) - PART B: STATEMENT OF LOST OR STOLEN LICENSE 13. Please state the reason you are seeking a duplicate license. If you need more space than is available, please attach a second sheet to this application. PART C: 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 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 asbestos-related regulations may result in civil and/or criminal penalties. SIGNATURE OF APPLICANT: APPLICANT EMAIL ADDRESS: ______________________________ DATE SIGNED: / / American LegalNet, Inc. www.FormsWorkFlow.com