F-00039 - Asbestos Course Accreditation - Initial Application (Page 2 of 2) in pdf

F-00039 - Asbestos Course Accreditation - Initial Application Page 2

F-00039 (Rev. 3/09) Page 2 of 2

Name of Training Provider

COURSE APPLICATION MATERIALS

Check each box to confirm the application package includes the following course materials and information.

Index of submitted materials

Completed topic analysis worksheet

Training resources description

Course test and answer key

Recordkeeping description

Course test blueprint

Course registration plan

Evaluation form

Course agenda

Sample student training certificate

Student manual and materials

Course approval letter(s) from other states/EPA, if any

Instructor manual and materials

Asbestos company application, if not already certified

AFFIDAVIT OF APPLICANT (Signature required)

I state that all the answers set forth are strictly true in each respect. I understand that false or forged statements made in

connection with this application may be grounds for denying or revoking course accreditation, company certification or

individual certifications or approvals, or for taking other disciplinary or legal action. I also affirm that the training course

named in this application meets the requirements of ch. DHS 159, Wis. Adm. Code, Subchapter III, Accreditation of

Training Courses.

Date Signed (mm/dd/yy)

SIGNATURE – Owner or Designated Asbestos Coordinator

SUBMITTING APPLICATION

Submit application, including completed application form, fees and required course materials, to DHS for review and

approval.

Forms, including company application form and credit card payment form, are available online at

or by calling (608) 261-6876.

If mailing the application, use the mailing address below. If hand delivering, use the street address.

Mailing Address

Street Address

Department of Health Services

Asbestos and Lead Section, Room 137

Asbestos and Lead Section

PO Box 2659

1 West Wilson Street, Room 137

Madison WI 53701-2659

Madison WI 53703

F-00039 - Asbestos Course Accreditation - Initial Application Page 2