New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Environmental and Occupational Health Assessment Program

PO Box 372

Trenton, NJ 08625-0372

Telephone: 609-826-4950 / Fax: 609-826-4975

Request for Reciprocity

Verification of Lead Licensure Status with new york state

Directions: Applicants using New York State (NYS) certification issued after July, 2014 to apply for a New Jersey lead permit must complete Section I of this form and submit the form to their NYS licensing office for completion. The licensing agency must complete Section II of this form. The completed form can either be faxed or mailed to our office by the licensing agency.

Please note:

This office will not accept Request for Reciprocity forms submitted directly to us by the applicant. This form must be submitted by licensing agency.

Reciprocity applications will not be approved without a completed Request for Reciprocity form.

Out-of-state certifications must be currently valid.

Fax the completed form to the EPA at 732-321-6757 or call them at 732-321-4374.
Section I - TO BE COMPLETED BY APPLICANT
Name (Last Name, First Name)

Out of State ID No. (if applicable)

Date of Birth

Discipline(s) applying for (check all that apply)

Lead Worker for Housing and Public Buildings	Lead Inspector/Risk Assessor*

Lead Supervisor for Housing and Public Buildings	Lead Planner/Project Designer

*Applicants must have a currently valid Lead Inspector/Risk Assessor or Lead Risk Assessor certification from another EPA‑authorized state in order to be eligible to apply for the Inspector/Risk Assessor certification in NJ.
Current Address

City

State

Zip Code

Daytime Telephone Number

Alternate Telephone Number

E-mail Address

Permission for Release of Information

I hereby give my permission to the Lead licensing office of the State of New York to release my information to the New Jersey Department of Health for purposes of obtaining a New Jersey Lead permit.
Signature	Date

Section II - MUST BE COMPLETED BY out-of-state lead licensing agency
The individual indicated above wishes to apply via reciprocity for New Jersey lead certification. Please provide the following information and return the completed form to the New Jersey Department of Health at the above address or fax number.
Name and Address of Licensing Agency

Telephone Number

Fax Number

Applicant Licensing Information
Discipline	License Number	Issuance Date	Expiration Date
Does this individual have any pending /outstanding penalty actions against them?

Yes No

If Yes, describe nature of pending/outstanding penalty actions:

Name of Licensing Representative (Print)	Title	Signature	Date

EHS-46

OCT 16

EHS-46 Request for Reciprocity, Verification of Lead Licensure Status with Another State Authorized by the US EPA to Administer a Lead Program

EHS-46, lead, reciprocity, licensure, verification, environmental, occupational, health, assessment,

ewhite

2016-10-14

NJDOH