INSTRUCTIONS FOR COMPLETING

“APPLICATION FOR REPLACEMENT OF LEAD PERMIT”	L
Please read the following directions carefully before completing and submitting the application. Failure to follow these directions could result in denial of your application for a permit.

General

( Application must be notarized (where indicated), typewritten or neatly and legibly printed in ink.

( Fully complete the entire application, sign and date the application, and mail it to the address indicated at the top of the application.

Application Fee, Discipline, Permit Number and ID Number

( Fee: Must include a certified check or money order (no personal checks or cash) for $25 made payable to “New Jersey Department of Health.”

( Discipline: Check the discipline of the permit which was lost, mutilated or stolen.

( Permit Number: When issued, all permits are attached and mailed with a card which contains basic information found on your permit. The permit number can be found on that attachment.

( Permit Number: When issued, all permits are attached and mailed with a card which contains basic information found on your permit. Your ID Number can be found on that attachment. Please Note: All individuals are assigned one ID Number, no matter how often they renew a permit or how many different types of Lead permits they apply for.

General Applicant Information

( Indicate name as it appears on your permit. If you have changed your name and wish to have your new name on the permit, appropriate legal documentation must be submitted indicating the name change.

Social Security Number

( Pursuant to the Privacy Act, 5 U.S.C. 522a, the disclosure of social security numbers is voluntary.

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

Telephone Numbers and Email Address

( During the review process, it is often necessary to contact the applicant regarding questions on the application. It is necessary that you provide a means by which we can contact you regarding your application.

Reason for Replacement

( This section must be complete and concise and must include a detailed statement concerning the circumstances surrounding the loss, mutilation or theft of your permit. If the permit was stolen, a copy of the police report must accompany the application. All applications for the replacement of a mutilated or damaged permit must include the mutilated or damaged permit. Permits may only be replaced two times within the two-year permit period.

Attachments

All applications MUST include the following:

( Certified Check or Money Order in the amount indicated on the application

( No cash or personal checks will be accepted.

( Must be made payable to the "New Jersey Department of Health."

( Application fees are non-refundable.

( No liability shall be assumed by the Department for the loss or delay in transmission of the application fee.

( Permit replacement application must be accompanied by copies of two forms which verify the applicant’s identification. Copies must be notarized to validate that they are “true copies.”

( Applications to replace a worn or mutilated permit must include the worn or mutilated permit.
( Passport-size color photograph of yourself (see approximate size at right)

( Must be recent.

( Front face.

( Full face (at least 3/4” wide).

( No hat.

( No glasses.

( No other item which would disguise overall features.

( White background, without clutter.

( Clear.

( Name and ID number (from permit) or control number (on EHS-9 form) must be 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 REPLACEMENT OF LEAD PERMIT	FOR NJDOH USE ONLY
Transmittal No.: LT-
Date Received: / /
L
Check MO No.:
Amount: $	Initials:
Please type or print legibly in ink. Mail the original application, recent passport-size photo (see directions), a non-refundable certified check or money order (personal checks and cash will not be accepted), photocopies of two (2) forms of signature-bearing identification, and the damaged permit (as applicable) to the above address. Checks should be made payable to the "New Jersey Department of Health." If you have any questions, call the NJDOH at the above number.
I. APPLICATION FEE, DISCIPLINE, PERMIT NUMBER AND ID NUMBER
Fee:

$25.00	Discipline:

A. Worker-Housing and Public Buildings	D. Planner/Project Designer

B. Supervisor-Housing and Public Buildings	E. Worker-Commercial Buildings and Superstructures

C. Inspector/Risk Assessor	F. Supervisor-Commercial Buildings and Superstructures
Permit Number (see Directions)

Applicant’s NJ ID Number (see Directions)

II. 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

III. REASON FOR REPLACEMENT
Indicate Reason for Replacement

Has applicant requested a previous replacement since this permit was issued?

Yes No
Loss Mutilation Theft Never Received
Other:
Detailed circumstances surrounding the mutilation, loss or theft of your permit (attach any supporting documentation):
IV. APPLICANT STATEMENT AND SIGNATURE
The information contained in this "Application for Replacement of 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

Notary Public Information and Seal:

State of _________________________________

County of _______________________________

Sworn and subscribed before me this _______ day of ______________________, 20_____	(Seal)

My commission expires __________________________, 20_____

Signature of Notary _________________________________________________

Official Title _______________________________________________________
EHS-29

JUL 12

EHS-29, Application for Replacement of Lead Permit

EHS-29, EHS, Application, Replacement, Lead permit, indoor environments program

Elaine White

2002-05-14

ewhite

NJDOH