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:

RADON CERTIFICATION 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 is not currently certified by the New Jersey Department of Environmental Protection (NJDEP) to do Radon Testing. At this time, the applicant has not contracted with a company to conduct radon activities, but will sub-contract any such work to a company or individual who holds the proper NJDEP radon certification.	The above-named applicant is not currently certified by the New Jersey Department of Environmental Protection (NJDEP) to do Radon Testing. Indicate below the company (Section I.) or individual(s) (Section II.) you will sub-contract radon testing work to. A notarized copy of each currently valid NJDEP certification must be included for each company or individual listed.	The above-named applicant currently holds a Radon Testing Business Certification (complete Section I) or employs individuals (complete Section II.) who have a currently valid NJDEP certifications as indicated below. A notarized copy of each currently valid certification must be included for each company or individual listed.

SECTION I – COMPANY RADON CERTIFICATION INFORMATION
Company Name

Telephone

NJDEP 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 NJDCA, NJDEP, USEPA or any other Federal or State Agency?

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

SECTION II – INDIVIDUAL RADON CERTIFICATION INFORMATION
Certified Individual

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

Permit No.	NJDEP

ID No.	Expiration

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

*

Indoor Environmental Consultant License Application

Employee Qualifications: RADON CERTIFICATION INFORMATION

(Continued)

CEHS-14	* No longer employed or active. ** Attach resume.

MAY 14	Page _____ of _____ pages.

CEHS-14, Employee qualifications, radon certification information

CEHS-14, radon certification information, CEHS, indoor environmental consultant license application, employee qualifications, child care centers

ewhite

2012-03-20

NJDOH