APPLICATION FOR INDIVIDUAL ASBESTOS LICENSE IDEM – Office of Air Quality Asbestos Program 100 N. Senate Avenue Indianapolis, IN 46204-2251 Phone: (317) 233-3861 http://www.in.gov/idem State Form 43786 (R5 /10-07) Approved by State Board of Accounts, 2007 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT • 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. • NOTE: Return this form, required addenda, and check or money order made payable to "IDEM Asbestos Trust Fund" by mail to: APPLICATION TYPE Type of application (check one): Initial license Cashier – Mail Code 50-10C Indiana Dept of Environmental Management 100 North Senate Avenue Indianapolis, Indiana 46204-2251 Renewal license PART A: GENERAL INFORMATION - TO BE COMPLETED BY ALL APPLICANTS 1. Applicant Name Last First 2. Home telephone number: ( 3. Address where license should be mailed Street 4. Birth date City State Company name (if applicable): 5. ) Middle Initial Month 6. Day / Company telephone number: Sex Male Year / ZIP code 7. 8. Height Weight 9. ( ) - Eye Color 10. Hair Color feet Female pounds inches PART B: PHOTOGRAPHIC IDENTIFICATION - APPLIES TO ALL APPLICANTS ► Pursuant to 326 IAC 18, the applicant shall provide the Department two (2) copies of a clear and recent one and one-half LEAVE THESE SPACES BLANK inch (1-1/2") by one and one-half inch (1-1/2") identifying color FOR OFFICE USE ONLY photograph. Please enclose your photographs with this application. PART C: EDUCATION ► High School 11. High School Name, City & State: 12. High school degree? No Yes Date received: ► College _____________________________________ 13. GED Certificate / / No Yes Date received: / / 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 (R5 / 10-07) Application for Individual Asbestos License PART D: 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, 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 Employer name: Employer telephone number: ( ) - Employer address – Street City State Zip code Type of business or organization: Exact title of position: Name/title of immediate supervisor: Specific job duties (in detail): Dates employed (month/year) FROM / TO Employment type Part-time / Number of Hours/week Number of Employees you supervised Full-time WORK EXPERIENCE #2 Employer name: Employer telephone number: ( ) - Employer address – Street City State Zip code Type of business or organization: Exact title of position: Name/title of immediate supervisor: Specific job duties (in detail): Dates employed (month/year) Employment type FROM / / Number of Employees you supervised Part-time TO Number of Hours/week Full-time PART E: ASBESTOS TRAINING INFORMATION ► Pursuant to 326 IAC 18, provide a copy of all required certificates of training indicating successful completion of Indiana-approved initial course(s) and any requisite refresher training course(s). • • Initial License: You must attach a copy of your Indiana-approved initial training certificate and all Indiana-approved refresher training certificates, if any, for every license for which you are applying. Renewal License: You must attach a copy of your current Indiana-approved 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. Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 43786 (R5 / 10-07) Application for Individual Asbestos License PART F: LICENSE FEES 14. Listed below is the annual license application 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. Note: Inspector Management Planner Project Designer Project Supervisor $100 $100 Worker Make all checks and money orders payable to "IDEM Asbestos Trust Fund". $100 $100 $50 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 G: NOTES ► IMPORTANT • • • • • Allow a minimum of four (4) 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 addenda. Sign and date the application and return it to the Cashier address shown on page one (1) of this application. Applications will be returned which are incomplete or contain errors in response to any questions on the form and 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 IAC 18. 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. Applicants must enclose two (2) 1-1/2 inch by 1-1/2 inch recent color photographs of themselves. License(s) cannot be issued without photographs. Applicants must sign the two (2) signature cards at the bottom of this page. PART H: 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 I: SIGNATURE CARDS Applicant must sign both signature cards below. Application will be denied if signature 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 ASBESTOS-RELATED ACTIVITIES AS PRESCRIBED BY 326 IAC 18. SIGNATURE SIGNATURE Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com