Application For Individual Asbestos License {43786}

Reset Form INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY Asbestos Licensing Program 100 N. Senate Avenue, Room 1003 Indianapolis, IN 46204-2251 Telephone: (317) 233-3861 www.asbnotify@idem.in.gov APPLICATION FOR INDIVIDUAL ASBESTOS LICENSE State Form 43786 (R8 / 7-15) Approved by State Board of Accounts, 2015 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. · Submit a check or money order in the amount of the license fee associated with the discipline you are applying for. A list of license fees is provided on page three (3) of this application. Make the check or money order payable to the "IDEM Asbestos Trust Fund." Mail all required documents to: Mail Code 61-52 Indiana Dept of Environmental Management 100 North Senate Avenue, Room 1003 Indianapolis, Indiana 46204-2251 Type of Application (Check One) Initial L I C Refresher ATION TYPE PART A: GENERAL INFORMATION - TO BE COMPLETED BY APPLICANT 1. Name of Applicant Last ( ) - First Middle Initial 2. 3. Home Telephone Number: City Address Where License can be Mailed Street Name of Employer (if applicable): State ( ) - ZIP Code 4. Telephone Number of Employer: E-mail Address of Employer: 5. Date of Birth Day Year 6. Sex Male Female 7. Height Feet Inches 8. Weight Pounds 9. Eye Color 10. Hair Color Month / / PART B: EDUCATION REQUIREMENT FOR MANAGEMENT PLANNER\BUILDING INSPECTOR/PROJECT DESIGNER High School 11. High School Name, City & State: 12. High school degree? Yes No Date received: / / _______________________________________________________________________________ 13. GED Certificate Yes No 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 (R8 / 7-15) Application for Individual Asbestos License PART C: WORK EXPERIENCE FOR AN INITIAL LICENSE AS A SUPERVISOR, MANAGEMENT PLANNER, OR PROJECT DESIGNER 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 Name of Employer Address of Employer ­ Street City State ZIP Code Telephone Number of Employer: ( ) - Type of Business Title of Position E-mail Address of Employer Specific Job Duties Dates Employed (month/year) Type of Employment Part-time From / Number of Hours/week Number of Employees You Supervised To / Full-time WORK EXPERIENCE #2 Name of Employer Telephone Number of Employer: ( ) - Address of Employer ­ Street City State ZIP code Type of Business Title of Position E-mail Address of Employer Specific Job Duties Dates Employed (month/year) Type of Employment From / / Part-time Full-time Number of Hours/week Number of Employees You Supervised To Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com  INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 43786 (R8 / 7-15) Application for Individual Asbestos License PART D: ASBESTOS TRAINING INFORMATION REMINDER An initial license needs to submit your initial training certificate and each refresher thereafter. For a license renewal you only need to include your most recent refresher training certificate with the application. If copies of your most recent training certificate(s) are not included with your application, the license will be denied pending submittal of the required training certificate(s). PART E: LICENSE FEES Listed below is the annual license 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. Inspector Management Planner Project Designer Project Supervisor Worker $100 $100 $100 $100 $50 ________ Note: 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 F: NOTES IMPORTANT Allow a minimum of two (2) 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 documents. Sign and date the application and return it to the Cashier address shown on page one (1). Applications will be returned which are incomplete or contain errors in response to any questions on the application. This 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 IAC18. 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. I hereby certify that there are no misrepresentations 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: _ DATE / / E-MAIL ADDRESS OF APPLICANT: ______________________________________________________________________________ Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com