New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Indoor Environments Program

P.O. Box 369

Trenton, NJ 08626-0369

INDOOR ENVIRONMENTAL CONSULTANT

LICENSE RENEWAL APPLICATION

[Non-Refundable Application Fee: $2,000.00]	NJDoh Use Only
Tracking No.	Date Received
Check Money Order

Number: ______________________
Logged In By:
Directions:

Applicant must fully complete Sections I, II and V.

For Sections III, IV, and V, the applicant must check either “There have been no changes since prior application” or “Changes have occurred since prior application” boxes. If there have been changes, you must provide any new information.

The application and fee must be sent to the above address 30 days prior to the expiration of your license.
I. General Consultant Information
Legal Name of Company (Do not abbreviate.)

IEHA License No.

Physical Address	Mailing Address
Street Address

Street Address

City

State

Zip Code

City

State

Zip Code

Telephone No.

Fax No.

Telephone No.

Fax No.

Federal Tax ID Number

Unemployment Registration No

Check if Not Applicable	NJ Corporate Registration No.

Check if Not Applicable
II. Errors and Omissions Insurance
Must provide proof of a minimum $1,000,000 per occurrence for liability or errors and omissions insurance. Must include copy of certificate of insurance. Insurance company must be approved by the New Jersey Department of Banking and Insurance to write policies with an “A” rating or better from Best, Inc. Insurance coverage must be in effect the entire period for which a consultant is licensed.
Policy Number

Name of Insurance Carrier

Insurance Carrier Telephone No.

Policy Period

III. Primary Contact Information
Check one of the following:

There have been no changes since prior application. (Go to Section IV.)

Changes have occurred since prior application. (Complete this section.)
Name

Email Address

Street Address

City

State

Zip Code

INDOOR ENVIRONMENTAL CONSULTANT LICENSE RENEWAL APPLICATION

(Continued)
Check One of the Following:

There have been no changes since prior application. (Go to Section IV.)

Changes have occurred since prior application. (Complete this section.)	Additional Sheet Used
1	Name (Full Legal Name)

Date of Birth

Title

Percent Ownership

Street Address

City

State

Zip Code

2	Name (Full Legal Name)

Date of Birth

Title

Percent Ownership

Street Address

City

State

Zip Code

3	Name (Full Legal Name)

Date of Birth

Title

Percent Ownership

Street Address

City

State

Zip Code

4	Name (Full Legal Name)

Date of Birth

Title

Percent Ownership

Street Address

City

State

Zip Code

IV. Employee Qualifications
Check one of the following:

There have been no changes since prior application. (Go to Section V.)

Changes have occurred since prior application. See directions below.

▪Complete CEHS-13 for each new employee.

▪Revise previously submitted CEHS-10, CEHS-11, CEHS-12 and CEHS-14 (as appropriate).

▪Provide any additional information (i.e., staff no longer employed by consultant) on a separate sheet.
V. Certification Statement
I certify that all the information provided on this application or supplied on any documents submitted for the purposes of certification is true and accurate to the best of my knowledge. I understand that the falsification of any documentation may result in the rejection of my application and/or the assessment of an administrative penalty of up to $25,000 per day for the first offense and $50,000 per day for the second and each subsequent offense. I understand that this application is subject to verification and that I agree to provide any additional documentation as required. For the same purposes, I understand that outside sources may be contacted and I do hereby give my permission for disclosure of any information provided to determine certification validity and/or eligibility. I understand that failure to provide full disclosure of all required information may result in the denial of this application. I understand that the completion of this application does not guarantee certification to conduct Indoor Environmental Health Assessments of child care facilities.
Name of Representative (Please Print or Type)

Title

Signature	Date

CEHS-16

JUN 15	Page 2 of 2 pages.

JUN 15	Page 1 of 2 pages.

CEHS-16, Indoor Envornmental Consultant, License Renewal application

indoor environmental consultant, CEHS-16, license renewal application, IEP

ewhite

2012-03-20

NJDOH