New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Indoor Environments Program

PO Box 369

Trenton, NJ 08625-0369	Indoor Environmental Consultant License Application

Employee Qualifications:

lead inspectors/risk assessor and evaluation contractor information
Directions for Completion:

(1) Type or legibly print all information. (2) Complete the page number and number of pages for this form on the bottom right corner of each page. (3) Please include all currently approved staff and staff that need to be removed or added to your list.

Full Legal Name of Applicant (as it appears on the CEHS-9 Application form)

Reason for Submission

New Application Revision
You must check one of the following:
The above-named applicant does not currently hold a New Jersey Department of Community Affairs Lead Evaluation Firm license. At this time, the applicant has not identified a licensed Lead Evaluation firm that they will use, but will sub-contract any lead inspection and/or risk assessment activities to a company who does hold that license.	The above-named applicant does not currently hold a New Jersey Department of Community Affairs Lead Evaluation Firm license. The applicant will sub-contract any lead inspection and/or risk assessment work to the licensed Lead Evaluation firm indicated in Section I. below.	The above-named applicant currently holds a New Jersey Department of Community Affairs Lead Evaluation Firm license. Complete Sections I and II below and include a notarized copy of your Lead Evaluation Firm license. Attach resumes, diplomas and a notarized copy of a current lead Inspector/Risk Assessor permit for each employee who holds that certification.

Section I - Company Certification Information

(Must include notarized copy of license)
Company Name

Telephone

NJ DCA Certification No.

Expiration Date

No. Years Certified

Physical Address

City

State

Zip Code

Mailing Address	Same as Physical Address

City

State

Zip Code

Has this company been issued a violation from the NJ DCA, NJ DEP, USEPA or any other Federal or State Agency?

Yes No (If yes, attach a statement describing circumstances )

Section II - Lead Inspector/Risk Assessor Information

(Include notarized copy of permits/licenses and certifications)
Certified Individual

(Last Name, First Name, MI)	Status of Staff	Date of Birth	NJDOH

Permit No.	NJDOH

ID No.	Expiration

Date	Number of Years of Relevant Experience **
New	Existing	Inactive

*

Indoor Environmental Consultant License Application

Employee Qualifications: LEAD Inspectors/RISK ASSESSOR AND EVALUATION CONTRACTOR INFORMATION

(Continued)

CEHS-10	* No longer employed or active. ** Attach resume.

MAY 14	Page _____ of _____ pages.

CEHS-10, Employee Qualifications, Lead Inspectors/Risk Assessor and Evaluation Contractor Information

CEHS-10, employee qualifications, indoor environments program, risk assessor and evaluation contractor information, cehs,

ewhite

2012-03-20

NJDOH