Application For Duplicate Lead License {50746}

APPLICATION FOR DUPLICATE LEAD LICENSE State Form 50746 (R6 / 4-11) INDIANA STATE DEPARTMENT OF HEALTH INSTRUCTIONS: 1. This form must be used to apply for a duplicate lead license 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. 2. Please type or print. 3. Return this completed form to the address provided in the upper-right hand corner of this page. PART A: GENERAL INFORMATION 1. Specify the discipline(s) for which you need a duplicate lead license(s): Inspector Project Supervisor Contractor Risk Assessor 2. Applicant name Last Clearance Examiner Project Designer Worker First Middle Initial 3. Mailing address Street City State ZIP code 4. 6. Company name (if applicable): Date of birth Day Year 5. 8. Height feet inches pounds 9. Weight 10. Eye color Company telephone number: 11. Hair color ( ) - 7. Sex Male Female Month 12. Home telephone number ( ) - / / 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: 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 lead-related regulations may result in civil and/or criminal penalties. SIGNATURE OF APPLICANT: ___________________________________________ DATE SIGNED: / / PART D: SIGNATURE CARDS Applicant must sign both of the signature cards below. Application will be denied if the cards are not signed. THIS LICENSE IS ISSUED FOR THE SOLE USE OF THE UNDERSIGNED AND IS NON-TRANSFERABLE. ANY USE OR POSSESSION, EXCEPT AS PRESCRIBED, IS PROHIBITED BY LAW. THIS LICENSE MUST BE IN THE POSSESSION OF THE UNDERSIGNED WHEN PERFORMING LEADRELATED ACTIVITIES AS PRESCRIBED BY 410 IAC 32. THIS LICENSE IS ISSUED FOR THE SOLE USE OF THE UNDERSIGNED AND IS NON-TRANSFERABLE. ANY USE OR POSSESSION, EXCEPT AS PRESCRIBED, IS PROHIBITED BY LAW. THIS LICENSE MUST BE IN THE POSSESSION OF THE UNDERSIGNED WHEN PERFORMING LEADRELATED ACTIVITIES AS PRESCRIBED BY 410 IAC 32. SIGNATURE SIGNATURE American LegalNet, Inc. www.FormsWorkFlow.com