Asbestos Certification Application Form
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Bureau of Environmental & Occupational Health
F-44017 (Rev 9/2015)
DHS 159, Wis. Adm. Code
Page 1 of 2
ASBESTOS CERTIFICATION APPLICATION – INDIVIDUAL
Please read instructions on Page 2 before completing both pages of this form. Failure to complete all sections will delay processing.
Under sections 250.041 and 254.115, Wis. Stats., an individual must provide their Social Security Number to be certified. The Social Security Number
(SSN) may be used to deny or revoke certification of persons delinquent in payment of taxes or child support and will not be available to the public.
Personally identifiable information necessary for processing this application and 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 Certification
Renewal Certification -- DHS Certification No.:_______________________________
APPLICANT INFORMATION
Name (First, Middle, Last, including any suffix - Jr, Sr, III)
Social Security No.
Sex
Birth Date (mm/dd/yy)
Height
Weight
Female
Male
______Feet ______Inches
Mailing Address
City
State
Zip+4
Telephone No.
Cellphone No.
Email
COMPANY INFORMATION (Employer, or business if self-employed)
Company Name
DHS Asbestos Company No.
Mailing Address
City
State
Zip+4
Telephone No.
Cellphone No.
Fax No.
CERTIFICATION DISCIPLINES & FEES (Check the disciplines and fees that apply)
Discipline
Fee
Discipline
Fee
Asbestos Worker
$75
Asbestos Inspector
$175
Asbestos Supervisor
$125
Asbestos Management Planner
$125
Exterior Asbestos Worker
$125 (one-time)
Asbestos Project Designer
$175
Exterior Asbestos Supervisor
$75
Replacement Card (Check Discipline)
$25
Total Amount Enclosed:
$_______________
Fee paid by check or money order payable to DHS. Cash is not accepted. To pay by credit card apply online at A
$25 processing fee applies to applicants submitting an out-of-state training history to DHS for the first time. Fees cannot be refunded or
prorated. An additional fee will be charged for checks not honored by the bank.
TRAINING (The most recent training class attended must be in Wisconsin)
Training Provider
Training Course
Training Dates (mm/dd/yy)
Start:
End:
OTHER LICENSES, CERTIFICATIONS OR APPROVALS
Within the past 5 years, did you have an asbestos license or certification issued by another state?
Yes
No
If yes, provide the discipline(s) and issuing state. (attach additional sheet, if needed)
ENFORCEMENT ACTIONS
Within the past 5 years, did you have an asbestos license or certification denied, suspended, or revoked by another state?
Or, within the past 5 years, was action taken against you for a civil or criminal violation of statute, regulation, or ordinance of the United
States, this state, any other state, or any local government substantially related to asbestos activities or other environmental activities?
Yes
No If yes, what action was taken, why and by whom?
Complete and sign Page 2.
DCF Check
Pers. Check
Co. Check
Money Order
Deposit Date
Amount Paid
For Office
Use Only
No.:
$
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