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:

GENERAL INDOOR ENVIRONMENTAL HEALTH ASSESSOR
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

1. Applicants must employ at least one individual with at least one year of experience doing indoor air quality assessments.

2. Applicants must employ at least one individual who has at least one year of experience doing environmental consulting.

You must complete the information below for each individual who meets one or both of the qualifications:

General Indoor Environmental Health Assessor Information

(Must include resume and notarized copy of permits/licenses and all certifications held.)
Check Type of Experience

(Check both if applicable)	Individual

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

Birth	Number of Years of Experience **	Type of Work Done
Indoor

Air Quality Assessments	Environmental Consulting
New	Existing	Inactive

*
CEHS-12

MAY 14	* No longer employed or active ** Attach resume.	Page of

Indoor Environmental Consultant License Application

Employee Qualifications: general indoor environmental health assessor

(Continued)

CEHS-12, employee qualifications, general indoor environmental health assessor

cehs-12, health assessor, indoor environmental consultant, license application, employee qualifications, cehs

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2012-03-20

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