Application For Individual Lead License {49240}

APPLICATION FOR INDIVIDUAL LEAD LICENSE State Form 49240 (R7 / 4-11) Approved by State Board of Accounts, 2011 INDIANA STATE DEPARTMENT OF HEALTH INSTRUCTIONS: 1. This form must be used to apply for licenses pursuant to 410 IAC 32. 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, 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 "ISDH Lead and Healthy Homes Program" by mail to: Cashier's Office Indiana State Department of Health PO Box 7236 Indianapolis, Indiana 46207 APPLICATION TYPE: Type of application (check one): 2. 3. Initial license Renewal of license PART A: GENERAL INFORMATION - TO BE COMPLETED BY ALL APPLICANTS 1. Applicant name Last First Middle Initial 2. 4. Home telephone number: ( ) City 3. E-mail address: State ZIP code Address where license should be mailed Street 5. Company name (if applicable): 7. Date of birth Month Day Year 6. 9. Height: feet inches Company telephone number: 10. Weight: pounds 11. Eye color: ( ) - / / 8. Sex: Male Female 12. Hair color: PART B: PHOTOGRAPHIC IDENTIFICATION - APPLIES TO ALL APPLICANTS Pursuant to 410 IAC 32-2-4(e) and 32-2-5(c), 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 digital photograph to be added to their file. Please enclose your photographs with this application. LEAVE THESE SPACES BLANK FOR OFFICE USE ONLY PART C: LICENSE RECIPROCITY ARE YOU APPLYING FOR INDIANA LEAD LICENSE(S) BASED ON LICENSE RECIPROCITY?: YES - Follow instructions below NO - Skip to Section D and complete the rest of application Persons applying for an Indiana lead license under license reciprocity (410 IAC 32-2-7) must do the following: Complete parts A, B, C, G, and I of this application. Attach to this application a legible copy of all current lead-based paint program licenses. If applicant is applying for Inspector, Risk Assessor, Project Designer, or Project Supervisor licenses, provide proof that applicant passed the appropriate third-party examination(s). Provide proof that applicant has attended an Indiana-approved Indiana 2 Hour Rules Awareness course. Pay the appropriate license application fee(s) outlined in Part G of this application. Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 49240 (R7 / 4-11) Application for Individual Lead License 4/11 PART D: EDUCATION High School 12. High school name, city & state: 13. High school degree? No Yes - Date received: / / 14. GED Certificate No Yes - Date received: / / PART E: 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. A resume may be attached instead of completing this section. 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 telephone number: ( ) - Dates employed FROM / TO / (Month / Year) (Month / Year) Employment type Part-time Full-time Number of hours/week Number of 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 telephone number: ( ) - Dates employed FROM / TO / (Month / Year) (Month / Year) Employment type Part-time Full-time Number of hours/week Number of employees you supervised PART F: LEAD TRAINING INFORMATION Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 49240 (R7 / 4-11) Application for Individual Lead License 4/11 Pursuant to 410 IAC 32, provide a copy of all required certificates of training indicating successful completion of approved initial course(s) and any requisite refresher training course(s). · · Initial License: You must attach a copy of your initial training certificate and all refresher training certificates, if any, for every license for which you are applying. NOTE: If your training is not Indiana-approved, you must also attach a copy of your Indiana-approved Indiana Rules Awareness course certificate. Renewal License: You must attach a copy of your current 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. PART G: LICENSE FEES 15. Listed below is the annual license application fee for each discipline. Check the appropriate box for each discipline for which you are applying and enter the total amount enclosed. Inspector Risk Assessor Project Supervisor Project Designer Worker $150 $150 $150 $150 $150 INSTRUCTIONS: Make all checks and money orders payable to "ISDH Lead and Healthy Homes Program". Per HEA 1725 (effective 5/3/99), local, city, county, and state government agencies are exempt from lead license fees. Pursuant to 410 IAC 32-2-9, the nonrefundable application fee is not: transferable from one (1) type of lead 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. Clearance Examiner $150 Total enclosed: $ PART H: REGISTRATION FOR LEAD-BASED PAINT THIRD-PARTY EXAM(S) If you have not already taken appropriate lead third-party exam(s) and you want to take the exam(s) in Indiana, please fill out the attached Indiana third-party exam registration form (State Form 50748) only when applying for an initial Inspector, Risk Assessor, Project Supervisor and/or Project Designer license(s) and only if you have already completed the requisite training courses. PART I: SIGNATURE IMPORTANT · · · · · Allow one (1) to two (2) weeks for processing of a complete application package and receipt of your license(s). Make sure you have completed all appropriate s