Form 45703 - Application For Radon Tester / Mitigator Certification
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1
2APPLICATION FOR RADON TESTER / MITIGATOR CERTIFICATION
State Form 45703 (R3 / 2-10)
Approved by State Board of Accounts, 2010
Indiana State Department of Health
or
Indiana State Department of Health, Attn: Cashier’s Office, PO Box 7236, Indianapolis, IN 46207-7236
will
TYPE OF CERTIFICATION
The fee for each certification is one hundred dollars ($100.00).
Radon Laboratory Tester
Primary Radon Tester
Secondary Radon Tester
Radon Mitigator
INDIVIDUAL INFORMATION
Name (
)
Home telephone number
(
)
Address (
)
BUSINESS INFORMATION
Name of business
Address (
)
Business telephone number
Business e-mail address
(
)
Name of president or chief executive officer (
)
RADON PROFICIENCY PROGRAM (RPP) INFORMATION (Complete all that apply.)
RPP Identification Number for Residential Measurement
RPP Identification Number for Analytical Measurement
RPP Identification Number for Residential Mitigator
RADON MEASUREMENT SERVICES
Type of service provided
RADIOACTIVE MATERIALS
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