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ILLINOIS DEPARTMENT OF PUBLIC HEALTH

DIVISION OF ENVIRONMENTAL HEALTH

LICENSE APPLICATION FOR

LEAD SUPERVISOR, LEAD INSPECTOR AND LEAD RISK ASSESSOR

Check type of license applied for:

Lead Supervisor $50.00

Lead Inspector $100.00*

Lead Risk Assessor $100.00*

*When applying for Risk Assessor a separate Lead Inspector license/exam is not needed.

Check or money order shall be made payable to the Illinois Department of Public Health (IDPH). All fees are

non-refundable. Applicants for lead supervisor, lead inspector and lead risk assessor shall submit a $50.00

Party exam fee and a completed exam application. All applicants shall submit a current 1” x 1” photograph

for each type of license, copies of appropriate training certificates, experience and education requirements.

APPLICANT NAME:________________________________________/______________________________/_________

Last Name

First Name

Middle Initial

HOME ADDRESS:___________________________________________________

APT# or FLOOR______________

CITY:___________________________________________________STATE:___________ZIP CODE:______________

COUNTY:___________________ HOME PHONE:_(_____)______________DOB_________SS#__________________

In accordance with the requirements of the Illinois Administrative Procedure Act, 5 ILCS 100, the Department

of Public Health requires the disclosure of your social security number as part of the license application.

Failure to provide your social security number shall result in the denial of your license application.

EMPLOYER:______________________________________________________________________________________

EMPLOYER ADDRESS:_____________________________________________________________________________

CITY:___________________________________________________STATE:___________ZIP CODE:______________

COUNTY:__________________________PHONE:_(_____)_________________FAX:__(_____)__________________

It is required by law (5ILCS/100/10-65) that all applicants shall complete and sign the following

statement: FAILURE TO COMPLETE AND SIGN THE CHILD SUPPORT STATEMENT will result in

the return of your application and delays in processing your license. Making a false statement may place you

in CONTEMPT OF COURT. I hereby certify, under penalty of perjury, that

I am more than 30 days delinquent in complying with any child support order.

I am NOT more than 30 days delinquent in complying with any child support order.

This statement does not apply.

I hereby certify that the information submitted is true and valid, and I understand that the Illinois Department of Public

Health may deny, suspend or revoke my Lead License for knowingly making false or fraudulent claims.

______________________________/___________

License will not be issued without a current photo.

Signature of Applicant

Date

IMPORTANT NOTICE

The Public Information Disclosure form accompanying this application

THIS

STATE

AGENCY

REQUESTING

DISCLOSURE

must be completed and returned to this office to allow the Department to

INFORMATION THAT IS NECESSARY TO ACCOMPLISH THE

release your contact information.

ONLY those lead professionals who

STATUTORY PURPOSE AS OUTLIEND UNDER PUBLIC LAW PA 87-

complete this form and return it to this office will be included in Department

175.

DISCLOSURE OF THIS INFORMATION IS MANDATORY.

lists. The Public Information Disclosure form is incorporated into all

FAILURE TO PROVIDE ANY INFORMATION COULD RESULT IN

license applications and training course provider approval applications to

DENIAL, REVOCATION OR SUSPENSION OF THE APPLICANT’S

address the release of contact information to the general public.

LICENSE.

License Application For Lead Supervisor, Lead Inspector And Lead Risk Assessor - Illinois Department Of Public Health

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