Fillable Asbestos Certification Application Form (Page 2 of 2) in pdf

F-44017 (Rev. 8/2015)

Page 2 of 2

Name of Applicant (First/Last)

ATTACHMENTS (Check that the following materials are included.)

Completed application

Fee - Check or money order payable to DHS

Training certificate(s), if needed – see instructions below for details

Completed asbestos company application form, if needed

COMPANY CERTIFICATION (Check most accurate response.)

Certified persons must work for or own a certified asbestos company before conducting regulated asbestos work.

I currently work for or, own a certified asbestos company, or certified exterior asbestos company.

I will work for a certified company when I do regulated work.

An asbestos company or exterior asbestos company certification application is enclosed.

AFFIRMATION OF APPLICANT (Signature required)

I state that I am the person referred to on this application and that all answers set forth are strictly true in each respect. I understand

that false or forged statements made in connection with this application may be grounds for denying or revoking my certification or for

other disciplinary or legal action. I also understand that if I am issued a certification card, failure to comply with the laws or rules of the

State of Wisconsin may be cause for disciplinary or legal action. I affirm that I currently work for or own a certified asbestos company or

certified exterior asbestos company, or that I will work for a certified company when conducting regulated work.

SIGNATURE – Applicant

Date Signed (mm/dd/yy)

SUBMITTING APPLICATION Call 608-261-6876 if you have questions.

Mailing Address

Street Address

Department of Health Services

Lead and Asbestos Section, Room 137

Lead and Asbestos Section

P.O. Box 2659

1 West Wilson Street, Room 137

Madison WI 53701-2659

Madison WI 53703

INSTRUCTIONS: To apply for renewal, complete this form and return with a check or money order in payment of the fee. To pay with

a VISA or MasterCard, apply online at

Incomplete or unreadable applications may delay processing and an additional processing fee may be charged.

CERTIFICATION

Check the Initial box if applying for a discipline for the first time or after a lapse of more than 12 months since expiration.

Check Renewal if applying before certification in the discipline has expired or within 12 months after expiration.

APPLICANT INFORMATION – Provide the personal information requested, including your Social Security number, which is required

by law. Applicants must be 18 years of age to qualify for certification. Provide the address where your certification card and renewal

notice should be mailed. You are required to notify the Department when your mailing address changes.

COMPANY INFORMATION – Provide the name of your employer, or if self-employed, the name under which you do business. To

help us associate your information with the correct company, also provide the DHS asbestos company certification number. You must

own, be employed by or under contract with a certified asbestos company before you may perform regulated asbestos abatement or

management activities.

CERTIFICATION DISCIPLINE & FEE – Place an ‘X’ in the box for the discipline and fee amount to be paid.

Enclose your check or money order payable to DHS. Fees cannot be refunded or prorated. DHS charges an additional fee for checks

not honored by the bank.

Payment by VISA or MasterCard credit or debit card may only be made if applying ONLINE at

TRAINING – First-time applicants who have taken more than one class in the discipline must provide copies of all course completion

certificates for the discipline (initial and refresher classes). No more than a 24-month gap is allowed between any two classes taken.

Your application will not be processed without your complete training history.

Applicants who are submitting one or more out-of-state training certificates for the first time must submit a $25 processing fee in

addition to the certification fee.

Your most recent training for the discipline must be taken in Wisconsin. Go to

for contact

information for Wisconsin asbestos training providers, or call 608-261-6876 for assistance.

AFFIRMATION OF APPLICANT – Read and personally sign the affirmation of your identity and accuracy of the information.

Clear / Reset Form

Asbestos Certification Application Form Page 2

Related Articles

Related forms

Related Categories