New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

PO Box 372, Trenton, NJ 08625-0372

609-826-4950

RENEWAL APPLICATION FOR

LEAD TRAINING AGENCY CERTIFICATION	FOR NJDOH USE ONLY
Transmittal No.: LT-
Date Received: / /
Amount: $
Check MO No.:
Initials:
Renewal applications must be submitted at least 180 calendar days prior to the expiration date of the discipline. Please type or print legibly in ink. One initial and corresponding refresher course may be submitted on an application. If you have any questions, please contact the NJDOH at the above number. Forward completed application to the above address.
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: Renewal
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

Agency Number

Mailing Address

Street Address (if different than mailing address)

City

State

Zip Code

City

State

Zip Code

Business Telephone

( )	Fax Number

( )
III. TRAINING MANAGER INFORMATION
Name

Position and/or Title with Company

Address

Telephone Number

( )
City

State

Zip Code

Email Address (if applicable)

IV. APPLICANT RE-CERTIFICATION INFORMATION
Is all of the information contained in the previous application still accurate?

Yes No

If you check “No” you must include any updated information or materials with this application.	If applicable, have any outstanding penalties been paid?

Yes No N/A

If you check “No” you must pay all penalties before your re‑certification can be approved.
V. APPLICANT STATEMENT AND SIGNATURE
The information contained in this "Renewal 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 certify that this agency can operate in compliance with N.J.A.C. 8:62.

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

Title

Signature	Date

EHS-2

JUL 12

EHS-2, Renewal Application for Lead Training Agency Certification

EHS-2, EHS, indoor environments program, lead, training agency, certification, renewal, application

ewhite

2011-04-15

NJDOH