F-44002 - Asbestos Certification Application - Company
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Bureau of Environmental and Occupational Health
F-44002 (Rev. 9/2012)
DHS 159, Wis. Adm. Code
Page 1 of 2
ASBESTOS CERTIFICATION APPLICATION – COMPANY
Company certification is required under s. DHS 159.14 before performing regulated asbestos abatement or management activities.
Application may be made using this form or online at
Incomplete or unreadable applications may delay processing and an additional processing fee of $25 may apply.
Under section 254.115, Wis. Stats., a company must provide its Federal Employer Identification Number (FEIN), or, if a sole proprietorship, the applicant’s
social security number (SSN), when applying for company certification. If the sole proprietor does not have a Social Security number, then a signed
statement made under oath or affirmation that the applicant does not have a social security number is required. Information collected on this form, other
than the SSN, may be shared with other government agencies for compliance review and may be available to the public under an open records request.
Applying for
Initial Company Certification
Renewal Company Certification - DHS No.:_____________________
COMPANY CONTACT INFORMATION Please print
Company Name
Federal Employer ID No. (FEIN), or sole proprietor’s name & Social Security No. (SSN)
Tax Status
For Profit
Nonprofit
Mailing Address
City
State
Zip+4
Records Street Address (if different)
City
State
Zip+4
Telephone No.-Include Area Code Fax No.–Include Area Code
Cellphone No.- Include Area Code Email
COMPANY ACTIVITIES
Check all that describe your business
Asbestos Abatement Contractor
Flooring Contractor
Roofing Contractor
Asbestos Consultant
Government:
Federal
Local
State
Siding Contractor
Asbestos Training Provider
Industrial-Manufacturing / Utility / Institutional /
University / College
Commercial
Construction / Renovation Contractor
K-12 School (public or private nonprofit)
Weatherization / CAP
Demolition Contractor
Property Owner or
Property Management
Other:
CERTIFICATION & FEE
Enclose check or money order payable to DHS.
Fees cannot be refunded or prorated. An additional fee is charged for checks not honored by the bank. Payment by VISA or MasterCard
credit or debit card is only accepted if applying ONLINE. Go to
to apply.
Asbestos company – $400
Satellite office – $200
May only apply for satellite office to an already certified company.
Exterior asbestos company – $200
Satellite office –$100
Certified Primary Office DHS____________________________
Replacement certificate – $25
Total Fee Enclosed: $_______________
Fee exempt:
WI state government
WI local government
WI K-12 school (public/private nonprofit)
WI University System
PUBLIC DIRECTORIES Check the directories for which you qualify and would like
to be listed for access by the general public
Asbestos Abatement Contractor directory – must employ a certified asbestos supervisor.
Exterior Abatement Contractor directory – must employ a certified asbestos supervisor or exterior asbestos supervisor.
Asbestos Consultant directory – must employ a certified asbestos inspector, management planner, or supervisor (for air monitoring).
Asbestos Training Provider directory – must have an accredited asbestos training course.
AFFIRMATION OF APPLICANT
Signature of an authorized company representative is required.
I state that I am an authorized representative of the company referred to on this application and that all the answers set forth are strictly
true in each respect. I understand that false statements made in connection with this application may be grounds for denial or revocation
of certification or other disciplinary or legal action.
Neither this company, nor any owner, officer or authorized representative of this company has been cited for a violation of a federal, state
or local asbestos regulation within the past three years (
except as described in the attached document).
SIGNATURE – Authorized Company Representative
Title
Date Signed (mm/dd/yy)
For DHS use only
Pers. Ck. No.
Co. Ck. No.
MO No.
Amount Paid
Deposit Date
$
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