F-00049 - Asbestos Principal Instructor Application
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Bureau of Environmental & Occupational Health
F-00049 (03/09)
DHS 159, Wis. Adm. Code
Page 1 of 2
ASBESTOS PRINCIPAL INSTRUCTOR APPLICATION
Under sections 250.041 and 254.115, Wis. Stats., an individual must provide his or her 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 application, other
than the SSN, may be shared with other government agencies as part of compliance review activities and may also be available under an
open records request by the public.
Applying for
Initial Approval
Renewal of Approval
APPLICANT INFORMATION
Name (First, Middle, Last, including any suffix - Jr, Sr, III)
Social Security No.
Mailing Address
City
State
Zip + 4
Telephone No.
Fax Telephone No.
Cellular Telephone No.
(
)
(
)
(
)
Pager No.
E-mail address
(
)
CERTIFICATIONS
Check the disciplines in which you hold current certification and list expiration date for each. Provide certification number.
Supervisor
Expiration Date
Exterior Supervisor
Expiration Date
DHS Certification No.
Inspector
Expiration Date
Management Planner
Expiration Date
Project Designer
Expiration Date
QUALIFICATIONS
Attach resume that describes all
Attach training certificate from a train-
Provide three professional references
relevant professional training and
the-trainer course with a minimum
or letters of recommendation, with no
work experience, including employers
length of 16-hours, or equivalent
more than one from current
and dates.
training. Include course description
employment.
or agenda or college transcript.
Reference Name
Reference Name
Reference Name
Title
Title
Title
Company
Company
Company
Work relation to applicant
Work relation to applicant
Work relation to applicant
Telephone Number
Telephone Number
Telephone Number
(
)
(
)
(
)
INSTRUCTOR DISCIPLINES & APPROVAL FEES (Check all that apply)
Asbestos Discipline
Courses may teach
Fee
Inspector
Asbestos inspector initial and refresher
$50
Management Planner
Asbestos management planner initial and refresher
$50
Project Designer
Asbestos project designer initial and refresher
$50
Supervisor
Asbestos worker, supervisor, exterior supervisor initial and refresher, and exterior worker
$50
Exterior Supervisor
Exterior asbestos worker and exterior asbestos supervisor initial and refresher
$50
Make check or money order payable to DHS, or enclose credit card payment form.
Total amount enclosed $
For DHS use only
Received Date
DWD Check
Paid Amount
Deposit Date
Entered into WALDO by
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