F-00049 - Asbestos Principal Instructor Application Page 2
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2F-00049 (03/09) Page 2 of 2
Name of Applicant (First, Middle, Last)
RENEWAL REQUIREMENTS (Complete this section if applying for renewal of approval)
I am currently certified in the appropriate discipline(s) as indicated above.
I attended at least one DHS training meeting within the past 4 years. Date of last meeting attended
Within the past 12 months I taught one or more asbestos classes in each discipline for which I am requesting renewal.
Last class taught in discipline
Class Dates
Last class taught in discipline
Class Dates
Last class taught in discipline
Class Dates
Last class taught in discipline
Class Dates
OTHER LICENSES, CERTIFICATIONS OR APPROVALS
Within the past 5 years, did you have an asbestos license, certification or approval issued by another state?
Yes
No If yes, which discipline(s) and who issued it?
ENFORCEMENT ACTIONS
Within the past 5 years, did you have an asbestos license, certification or approval 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?
AFFIDAVIT OF APPLICANT
I state that I am the person referred to on this application and that all the 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 instructor approval or for other disciplinary or legal action. I also understand that if I am approved as a principal
instructor, failure to comply with the laws or rules of the State of Wisconsin may be cause for disciplinary or legal action.
SIGNATURE – Applicant
Date Signed (mm/dd/yy)
ATTACHMENTS (Check the items being submitted with the application)
Application Form – Complete, accurate and legible.
Approval Fee – Check or money order payable to DHS, or completed credit card payment form.
Resume with dates and locations of relevant training and experience.
Train-the-Trainer training certificate and course description, or transcript from a college course. (Copy acceptable)
Any supporting letters or recommendation or reference.
SUBMITTING APPLICATION
Application and credit card payment forms are available online at
or by calling
(608) 261-6876.
If mailing your application, use the mailing address listed below. If hand delivering, use the street address provided below.
If paying by credit card, you may fax your application and attachments with the completed credit card form.
Return completed application to:
Fax Telephone Number – (608) 266-9711
Mailing Address
Street Address
Department of Health Services
Department of Health Services
Asbestos and Lead Section, Rm 137
Asbestos and Lead Section
P.O. Box 2659
1 West Wilson Street, Room 137
Madison WI 53701-2659
Madison WI 53703
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