New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Indoor Environments Program

PO Box 369

Trenton, NJ 08625-0369

Consultant/Employee Certification

I. Employee Information (matched to Employee Qualification forms)
Employee Name (Print or Type Legibly)

I hereby certify that all documentation submitted as proof of my qualifications as an Indoor Environmental Health Consultant Employee, to conduct Indoor Environmental Health Assessments is accurate, true and complete to the best of my knowledge. I understand that if such information contained in this application is false, I am subject to the penalty provisions under N.J.A.C. 8:50.

I understand that all information submitted is subject to verification and that I agree to provide any additional documentation as required. For the same purpose I also understand that outside sources may be contacted and that I do hereby give permission for disclosure of any information which may be needed to determine certification application validity and/or eligibility. I also understand that failure to provide full disclosure of any of the requested or required information may result in rejection of this application for approval. I also understand that completion of this application does not guarantee approval to perform Indoor Environmental Health Assessments in New Jersey.
Signature	Date

II. Consultant (Employer) Information
The information being submitted for the approval of the above-named employee to conduct Indoor Environmental Health Assessments of child care and educational facilities is accurate, true and complete to the best of my knowledge. I understand that if such information contained in this application is false, I am subject to the penalty provisions under N.J.A.C. 8:50.

I understand that this application is subject to verification and that I agree to provide any additional documentation as required. For the same purpose I also understand that outside sources may be contacted and that I do hereby give permission for disclosure of any information which may be needed to determine certification application validity and/or eligibility. I also understand that failure to provide full disclosure of any of the requested or required information may result in rejection of this application for approval. I also understand that completion of this application does not guarantee approval to perform Indoor Environmental Health Assessments in New Jersey

I am authorized to sign for and on behalf of the persons listed as owners, partners, shareholders, officers and directors of this company.
Company Name

Consultant Cert. No. (if applicable)

Authorized Consultant Representative (Print or Type Legibly)

Title

Authorized Consultant Representative Signature	Date

This form, and all accompanying information, must be sent to the

NJDOH, Indoor Environments Program by the consultant firm.

CEHS-13

JUL 12

CEHS-13, Consultant Employee Certification

CEHS-13, consultant employee certification, indoor environments program, CEHS, child care center

ewhite

2012-03-20

NJDOH