Form F-00040 - Asbestos Course Accreditation - Renewal Application
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1DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Bureau of Environmental & Occupational Health
F-00040 (3/09)
DHS 159, WIs. Adm. Code
Page 1 of 1
ASBESTOS COURSE ACCREDITATION – RENEWAL APPLICATION
Complete all sections of this application and submit with fee and any revised course materials. Under sections 254.115 and 250.041, Wis.
Stats., a company must provide its Federal Employer Identification Number in order to be accredited. This information is used to deny or
revoke certification of persons delinquent on payment of taxes or child support. Personally identifiable information necessary for processing this
application and collected on this form may be shared with other government agencies for compliance review and may be available to the
public under an open records request.
Renewal for:
Contingent Accreditation (may only renew twice)
Full Accreditation
COMPANY INFORMATION
Company Name
DHS Company No.
CONTACT INFORMATION (
Complete for any information that has changed since the last application)
Mailing Address
City
State
Zip+4
Records Street Address
City
State
Zip+4
Training Location Address (If different from mailing address)
City
State
Zip+4
Office Telephone No.
Fax Telephone No.
Cell Telephone No.
Pager No.
(
)
(
)
(
)
(
)
Course Contact Person
E-mail Address
COURSE AND ACCREDITATION FEE
Check the course included in the application. The accreditation fee is payable upon application. Fees may be paid by check or money order
payable to DHS, or by credit card using the Credit Card Payment form, DPH 44029.
Initial Course
Fee
Refresher Course
Fee
Asbestos Supervisor Course
$300
Asbestos Supervisor Course
$150
Asbestos Worker Course
$300
Asbestos Worker Course
$150
Asbestos Inspector Course
$300
Asbestos Inspector Course
$150
Asbestos Management Planner Course
$300
Asbestos Management Planner Course
$150
Asbestos Project Designer Course
$300
Asbestos Project Designer Course
$150
Exterior Supervisor Course
$300
Exterior Supervisor Course
$150
Exterior Worker Course
$300
REVISED COURSE MATERIALS
(Submit copies of all course revisions made since the last accreditation approval)
Revisions (Check all that apply)
Course agenda
Course test, answer key or blueprint
Student manual and materials
Evaluation form
Instructor manual and materials
Student training certificate
AFFIDAVIT OF APPLICANT
I state that 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 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.
SIGNATURE – Owner or Designated Asbestos Coordinator
Date Signed (mm/dd/yy)
SUBMITTING APPLICATION
If mailing application, use the mailing address below. If hand delivering, use the street address. If paying by credit card, you may fax the
application, revised materials and credit card form to (608) 266-9711. The credit card payment form is available online at
or by calling (608) 261-6876.
Mailing Address
Street Address
Department of Health Services
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
For DHS use only
Received Date
Amount Paid $
Deposit Date
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