INSTRUCTIONS FOR COMPLETING THE

“APPLICATION FOR LEAD PERMIT –

WORKER-COMMERCIAL BUILDINGS AND SUPERSTRUCTURES”	E
Before completing and submitting the application, please read the following directions carefully. Failure to follow these directions could result in the delay or denial of your application for a permit.

General

(	Application must be typewritten or neatly and legibly printed in ink. Complete the application per the instructions below. When done, mail the application (with any required attachments) to the address indicated at the top of the application.

(	Applications which are pending (incomplete) for more than one (1) year will be rejected.

(	Applications which have not included the correct application fee or contain no proof of the appropriate training will be returned.

Application Fee, Type and Discipline

(	Fee: Applicant must include payment of $80 with the application. See information regarding payments.

(	Initial Application: If you have never had a New Jersey permit (for this discipline) or you had a permit (for this discipline) and it has expired more than 90 days ago.

(	Renewal Application: If you have a New Jersey permit (for this discipline) and your permit has either not expired or has not been expired for more than 90 days.

Social Security Number

(	Pursuant to the Privacy Act, 5 U.S.C. 552a, the disclosure of social security numbers is voluntary.

(	The use of social security numbers is for statistical purposes only.

Telephone Numbers and Email Address

(	Should questions arise during the review of your application, it is necessary that you provide a means by which we can contact you regarding your application. Failure to do so can result in unnecessary delays in approving your application.

Applicant’s History of Legal Actions

(	If you check “Yes” to any of these items you MUST provide a detailed explanation to fully explain the circumstances.

Attachments

Training

(	Proof of appropriate training, no more than one (1) year old, must be included with the application.

Payment

(	All applications MUST include payment. Application fees are non-refundable. No liability shall be assumed by the Department for the loss or delay in transmission of the application fee.

(	Two ways to pay:

(	Certified Check or Money Order (no cash or personal checks):

Must be made payable to the "N. J. Department of Health" in the amount indicated on the application.

(	E-payment:

Go to http://www.nj.gov/health/eohap/payments. html. A copy of payment confirmation must be included with application.

Photograph

(	Applicants must include a passport-sized (approximately 2” x 2”) color photograph of the applicant with the applicant’s face not being less than three-quarters of an inch wide. Must have white, uncluttered background, with no hat, glasses or anything that disguises overall facial features.

(	Applicant’s name and ID Number (from permit) or control number (from top right corner of pink EHS-9 form) must be clearly printed on back of photo.

New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

PO Box 372, Trenton, NJ 08625-0372

609-826-4950

APPLICATION FOR LEAD PERMIT

WORKER FOR COMMERCIAL BUILDINGS AND SUPERSTRUCTURES	FOR NJDOH USE ONLY
Transmittal No.: LT-
E
Date Received: / /
Check MO No.:
Amount: $	Initials:
Please type or print legibly in ink. Mail the original application, education and experience documents (see directions), passport photo (see directions), and a certified check or money order (personal checks and cash will not be accepted) to the above address. Checks should be made payable to the "New Jersey Department of Health." The application fee is non-refundable. Initial applicants must submit a completed application within one year of completing their training. Renewal applicants must submit their application during the 90‑calendar day period prior to or the 90-calendar day period after their previous permit’s expiration. Any applications pending in excess of one year will be rejected. If you have any questions, call the NJDOH at the above number.
1. APPLICATION FEE, TYPE AND DISCIPLINE
Fee:

$80.00	Application Type (Check one):

A Initial B Renewal	Discipline:

E Worker-Commercial Buildings and Superstructures
Date(s) of Most Recent Worker-Commercial Buildings and Superstructures Training

Name of Training Agency

2. GENERAL APPLICANT INFORMATION
Last Name	First Name	M. I.

Social Security Number (see instructions)

__ __ __ - __ __ - __ __ __ __
Street Address

Home Telephone Number

( )
City

State

Zip Code

Daytime Telephone Number

( )
Date of Birth

__ __ / __ __ / __ __	Sex

Male Female	Email Address (if you have one)

Name of Current Employer

Employer Telephone Number

( )
Address of Current Employer

Race (Check one)

1 White, Non-Hispanic	2 Black, Non-Hispanic	3 Hispanic/Latino	4 Brazilian
5 Asian/Pacific Islander	6 Am. Indian/ Alaskan Native	7 Other (Specify):
Highest Level of Education (Check one)

A Some High School	C Vocational/Technical School	E Associates Degree	G Masters Degree
B High School or Equivalent	D Some College	F Bachelors Degree	H Doctorate Degree
Height	Are there any children 6 years or younger in your household?
Feet	Inches	No Yes If Yes: There are:	children 6 years or younger.
Weight	Has applicant’s name changed within the past 2 years?
Pounds	No Yes If Yes: Former Name:
3. APPLICANT HISTORY OF LEGAL ACTIONS
If you answer “Yes” to either of the following questions, you must provide a detailed statement to fully explain the circumstances and attach the statement to this application.
In relation to environmentally-related work activities conducted in any state, has/is the applicant, identified in Section 2 above:

Been subject to, or has pending, any disciplinary action(s), suspensions, or citation(s) of violation(s) by any administrative, governmental or regulatory agency, including, but not limited to, OSHA, EPA, NJDOL, NJDEP, NJDCA and NJDOH?	Yes No

Now or has been subject to any order resulting from any criminal, civil or administrative proceedings brought against such company, persons or parties by any administrative, governmental or regulatory agency?	Yes No
4. APPLICANT STATEMENT AND SIGNATURE
The information contained in this "Application for Lead Permit" 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. 8:62.

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 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 understand that failure to provide full disclosure of any of the requested or required information may result in rejection of this application. I understand that completion of this application does not guarantee certification to conduct lead-based paint activities in New Jersey.
Signature of Applicant:*
Date

EHS-26

DEC 15	* Please sign clearly with a black pen. Keep signature inside the box above.

EHS-26 (Instructions)

DEC 15

EHS-1 (Instructions)

AUG 15	Page 1 of 2.

EHS-26, Application for Lead Permit, Commercial Buildings and Superstructures

EHS-26, application, lead permit, commercial buildings, superstructures, indoor environments program

Elaine White

2002-05-23

ewhite

NJDOH