State Form 45703 - Application For Radon Tester / Mitigator Certification - Indiana State Department Of Health
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APPLICATION FOR RADON TESTER / MITIGATOR CERTIFICATION
State Form 45703 (R4 / 4-11)
Approved by State Board of Accounts, 2011
INDIANA STATE DEPARTMENT OF HEALTH
INSTRUCTIONS:
1. This is the radon certification application necessary to satisfy the requirements of 410 IAC 5.1-1-22. You must be
certified before you test, analyze or mitigate for radon-222 in Indiana. Submit the complete and accurate application, the
appropriate fee(s) and proof of successful completion and current listing on the Environmental Protection Agency’s
National Radon Measurement Proficiency Program (RPP), to be considered for Indiana certification. See the Indiana
Radon Rule 410 IAC 5.1 for additional information.
2. Type or clearly print all information.
3. Make personal check or money order payable to: Indiana State Department of Health.
4. Corporations MUST submit separate checks for each applicant.
5. Send the completed form to:
Indiana State Department of Health
ATTN: Cashier’s Office
2 N Meridian St
Indianapolis, Indiana 46204
6. Allow two (2) to three (3) weeks for processing. If you have any questions, please call 317-233-1250 and ask for the
Radon Coordinator.
TYPE OF CERTIFICATION DESIRED:
Check all that apply:
Radon Laboratory Tester – Fee: $ 100.00
Secondary Radon Tester – Fee: $ 100.00
Primary Radon Tester – Fee: $ 100.00
Radon Mitigator – Fee: $ 100.00
INDIVIDUAL INFORMATION:
1. Last Name:
2.
First Name:
3.
M. I.:
4.
Home Telephone Number: (
)
-
5.
E-mail Address:
6.
Address where license should be mailed (number and street):
7.
City:
8.
State:
9.
ZIP Code:
10. Company Name:
11. Company Telephone Number:
(
)
-
(if applicable):
12. Date of Birth:
13. Sex:
14. Height:
15. Weight:
16. Eye Color:
17. Hair Color:
Male
Month
Day
Year
feet
pounds
Female
/
/
inches
If this individual is applying for Radon Laboratory Tester and/or Radon Mitigator certification, the individual must be a full-time employee or
employer who shall be responsible for all laboratory and/or mitigation activities (as outlined in 410 IAC 5.1-1-24 and 5.1-1-26).
RADON PROFICIENCY PROGRAM (RPP) INFORMATION (COMPLETE ALL THAT APPLY):
RPP Identification Number for
RPP Identification Number for
RPP Identification Number for
Residential Measurement:
Analytical Measurement:
Residential Mitigator:
Enclose a copy of your RPP Photo ID Card. Also, if applying for Primary Radon Tester or Radon Laboratory
Tester, enclose a copy of your Device Performance Test Report (Listing Letter).
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