IDEM – Office of Air Quality Asbestos Program 100 N. Senate Avenue Rm. 1003 Indianapolis, IN 46204-2251 Phone: (317) 233-3861 www.in.gov/idem APPLICATION FOR DUPLICATE ASBESTOS LICENSE State Form 48740 (R2 / 4-08) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT 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. NOTE: No more than two (2) duplicate licenses will be issued to any one person in any calendar year. Please type or print. Return this completed form in person to the address listed in the upper-right hand corner of this page. PART A: GENERAL INFORMATION 1. Specify the discipline(s) for which you need a duplicate asbestos license(s): Inspector Project Supervisor Project Designer Management Planner Worker Contractor 2. Applicant Name Last First Address to which license should be mailed: Street City 3. 4. Birth Date State Company Name (if applicable): 6. Middle Initial Month 7. Day / Year / Sex Male Female 5. 8. Height 9. Weight Company phone #: 10. Eye Color ( ) 11. Hair Color - 12. Home telephone # feet inches ZIP code ( ) - 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: ___________________________________________ 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 ASBESTOSRELATED ACTIVITIES AS PRESCRIBED BY 326 IAC 18. 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 ASBESTOSRELATED ACTIVITIES AS PRESCRIBED BY 326 IAC 18. SIGNATURE SIGNATURE 6820-120000-420000 American LegalNet, Inc. www.FormsWorkflow.com