Application For Certification Of Lead Training Courses Form
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1
2
3Official Use Only
Paid: $
VERMONT DEPARTMENT OF HEALTH
Check #:
ENVIRONMENTAL HEALTH
M.O. #:
Asbestos & Lead Regulatory Program
Date:
108 Cherry Street, P.O. Box 70
Burlington, VT 05402
APPLICATION FOR CERTIFICATION OF LEAD TRAINING COURSES (1/09)
Please complete all sections of the application by printing or typing the required information, attaching all
required documentation, completing and enclosing the tax form. Applications submitted without the applicable
fee will be returned. Attach additional sheets as needed. The responsible person shall sign the application.
Contact the Program at (802) 863-7236 or (800) 439-8550 (in Vermont) with any questions.
Please submit a check to the Vermont Department of Health for the appropriate annual certification fee in the following categories:
APPLICATIONS MUST BE FILLED OUT COMPLETELY AND LEGIBLY
1) TRAINING ENTITY:
Name of Training Provider:
Responsible Individual:
Responsible Individual Title: _____________________________________________________________
Address:
City/Town:
State:
Zip:
Telephone No.:
_______
a
This applicant is (check one):
.
1) A Corporation
2) A Partnership
3) An Unincorporated Association
4) Sole Proprietorship
5) Other (specify)
--Attach organizational chart.
TYPE OF COURSE:
ndicate the training to be offered.
2.
I
INITIAL COURSES: (480.00 each)
REFRESHER COURSES ($480.00 each)
Worker (Target Housing/Public Bldgs)
Worker (Target Housing/Public Bldgs)
Worker (Superstructures/Commercial Bldgs)
Worker (Superstructures/Commercial Bldgs)
Supervisor (Target Housing/Public Bldgs)
_
Supervisor (Target Housing/Public Bldgs)
Supervisor (Superstructures/Commercial Bldgs
Supervisor (Superstructures/Commercial Bldgs)
Inspector Technician
Inspector Technician
Risk Assessor
Risk Assessor
Project Designer
Project Designer
3.
APPLICATION AND CERTIFICATION INFORMATION:
a)
CHECK ONE:
INITIAL CERTIFICATION:
RENEWAL CERTIFICATION:
If renewal
Certification # ______________ exp. Date _____________
Certification # ______________ exp. Date _____________
If this is a renewal application attach a photocopy of current training approval.
b) Does the courses have EPA or State approval? If so, which Region or State?
4.
COURSE SCHEDULING AND LOCATIONS
Please attach a proposed or projected schedule with dates and locations of training course offerings.
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