New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

PO Box 372

Trenton, NJ 08625-0372

609-826-4950

INITIAL APPLICATION FOR

LEAD TRAINING AGENCY CERTIFICATION	FOR NJDOH USE ONLY
Transmittal No.: LT-
Date Received: / /
Amount: $
Check MO No.:
Initials:
Please type or print legibly in ink. One Initial and corresponding refresher course may be submitted on a single application. Please refer to Lead Training Agency Certification Checklist for all additional information which must be submitted with this application. If you have any questions, please contact the NJDOH at the above number.
I. APPLICATION FEE AND COURSE TYPE
Course Fee: A non-refundable application fee for annual certification in the amount of $500.00 per discipline must be forwarded with this application. (Please Note that initial and refresher courses are two separate disciplines.) The fee must be paid by certified check or money order and be made payable to the "New Jersey Department of Health."
Type of Application: Initial
Course Discipline (Check no more than one initial and one corresponding refresher):

Worker-Housing and Public Buildings	Initial Refresher

Supervisor- Housing and Public Buildings	Initial Refresher

Worker-Commercial Buildings and Superstructures	Initial Refresher

Supervisor- Commercial Buildings and Superstructures	Initial Refresher

Inspector/Risk Assessor	Initial Refresher

Planner/Project Designer	Initial Refresher
II. GENERAL APPLICANT INFORMATION

Name of Company

Type of Company

Corporation Individual Partnership Other (specify):____________________
Mailing Address

City

State

Zip Code

Street Address (if different than mailing address)

City

State

Zip Code

Business Telephone

( )	Fax Number

( )
Federal Employer I.D. Number

Web Address (if applicable)

III. PRIMARY CONTACT INFORMATION
Name

Position and/or Title with Company

Address

Telephone Number

( )
City

State

Zip Code

Email Address (if applicable)

IV. APPLICANT (COMPANY) INFORMATION
How long has company/agency been in existence?
Years	Months
Has applicant’s name changed within the past 2 years?
No Yes If Yes: Former Name:
Is applicant approved by any federal, state or municipal office to conduct lead training?

No Yes If “Yes,” please attach a list of all approved courses, original date of approval and the approving authority
Is applicant an affiliate or a subsidiary of any other organization(s)?

Yes No If “Yes,” list name(s) and address(es) of related organization(s) and relationship:
Name	Address	Relationship
(Attach any additional names on a separate piece of paper)
List all owners, partners, shareholders (10% or more), officers and directors of the company below:
Name (Last, First, MI)	Address	Office/Title Held	% Ownership
(Attach any additional names on a separate piece of paper)
V. APPLICANT HISTORY OF LEGAL ACTIONS
If you answer “Yes” to any of the following questions, you must provide a detailed statement to fully explain the circumstances and attach the statement to this application.
Has/is the applicant identified in Section II 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

Been denied any license/certification/approval or had it suspended or revoked by any administrative, governmental or regulatory agency?	Yes No

Been disbarred, suspended or disqualified or failed inspection for training by any federal, state or municipal agency?	Yes No

Been a defendant in any civil or criminal litigation?	Yes No
VI. APPLICANT STATEMENT AND SIGNATURE
The information contained in this "Initial Application for Lead Training Agency Certification" 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 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 certification as a lead training agency in New Jersey.

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

Title

Signature	Date

INITIAL APPLICATION FOR

LEAD TRAINING AGENCY CERTIFICATION

(Continued)

EHS-28

JUL 12	Page 2 of 2 Pages.

JUL 12	Page 1 of 2 Pages.

EHS-28, Initial Application for Lead Training Agency Certification

EHS-28, EHS, Initial Application, Lead Training Agency, Certification, indoor environments Program,

Elaine White

2011-04-14

ewhite

NJDOH