F-00039 - Asbestos Course Accreditation - Initial Application
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Bureau of Environmental & Occupational Health
F-00039 (03/09)
DHS 159, WIs. Adm. Code
Page 1 of 2
ASBESTOS COURSE ACCREDITATION – INITIAL APPLICATION
Complete all sections of the application and submit with fee and required course materials as listed below. Review Wisconsin
Administrative Code Chapter DHS 159, Subchapter III, for a complete description of asbestos training course accreditation requirements.
Under sections 254.115 and 250.041, Wis. Stats., a company must provide its Federal Employer Identification Number in order to be
accredited. This information is used to deny or revoke certification of persons delinquent in payment of taxes or child support. Other
information necessary for processing this application and collected on this form may be shared with other government agencies for
compliance review and may be available to the public under an open records request.
COMPANY INFORMATION (Company must be a DHS certified Asbestos Company)
Company Name
Federal Employer Identification No.
DHS Asbestos Company Certification No. (if issued)
CONTACT INFORMATION
Mailing Address
City
State
Zip+4
Records Street Address (If different from mailing address)
City
State
Zip+4
Training Location Address (If different from mailing address)
City
State
Zip+4
Office Telephone No.
Fax Telephone No.
Cellular Telephone No.
Pager No.
(
)
(
)
(
)
(
)
Course Contact Person
E-mail Address
COURSE DISCIPLINE AND FEE INFORMATION
Check below the course discipline, applicable fees and total fee amount enclosed. The application fee and accreditation
fee are payable upon application. Fees may be paid by check or money order made payable to DHS, or by credit card
using the credit card payment form.
Initial Course
Accreditation Fee
Asbestos Worker Course
$300
Asbestos Supervisor Course
$300
Asbestos Inspector Course
$300
Asbestos Management Planner Course
$300
Asbestos Project Designer Course
$300
Exterior Worker Course
$300
Exterior Supervisor Course
$300
Refresher Course
Asbestos Worker Course
$150
Asbestos Supervisor Course
$150
Asbestos Inspector Course
$150
Asbestos Management Planner Course
$150
Asbestos Project Designer Course
$150
Exterior Supervisor Course
$150
For DHS use only
Received Date
Amount Paid
Deposit Date
$
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