Form EHS-4 "Initial Application for Asbestos Training Agency Certification" - New Jersey

What Is Form EHS-4?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2016;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form EHS-4 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form EHS-4 "Initial Application for Asbestos Training Agency Certification" - New Jersey

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New Jersey Department of Health
FOR NJDOH USE ONLY
Consumer, Environmental and Occupational Health Service
Transmittal No.: LT-
PO Box 372
Date Received:
/
/
Trenton, NJ 08625-0372
609-826-4950
Amount: $
INITIAL APPLICATION FOR
Check
MO No.:
ASBESTOS TRAINING AGENCY CERTIFICATION
Initials:
Renewal applications must be submitted at least 30 calendar days prior to the expiration date of the discipline you wish to renew.
Please type or print legibly in ink. One initial course and corresponding refresher course may be submitted on an application. If
you have any questions call 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:
Initial
Course Discipline (Check no more than one initial and one corresponding refresher):
Worker-Initial
Worker-Refresher
Supervisor-Initial
Supervisor-Refresher
II. GENERAL APPLICANT INFORMATION
Name of Company
Type of Company
Corporation
Individual
Partnership
Other (specify):____________________
Mailing Address
Street Address (if different than mailing address)
City
State
Zip Code
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 asbestos training?
No
Yes
If yes, please attach a list of all approved courses, original date of approval and the approving authority
EHS-4
MAR 16
Page 1 of 2 Pages.
New Jersey Department of Health
FOR NJDOH USE ONLY
Consumer, Environmental and Occupational Health Service
Transmittal No.: LT-
PO Box 372
Date Received:
/
/
Trenton, NJ 08625-0372
609-826-4950
Amount: $
INITIAL APPLICATION FOR
Check
MO No.:
ASBESTOS TRAINING AGENCY CERTIFICATION
Initials:
Renewal applications must be submitted at least 30 calendar days prior to the expiration date of the discipline you wish to renew.
Please type or print legibly in ink. One initial course and corresponding refresher course may be submitted on an application. If
you have any questions call 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:
Initial
Course Discipline (Check no more than one initial and one corresponding refresher):
Worker-Initial
Worker-Refresher
Supervisor-Initial
Supervisor-Refresher
II. GENERAL APPLICANT INFORMATION
Name of Company
Type of Company
Corporation
Individual
Partnership
Other (specify):____________________
Mailing Address
Street Address (if different than mailing address)
City
State
Zip Code
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 asbestos training?
No
Yes
If yes, please attach a list of all approved courses, original date of approval and the approving authority
EHS-4
MAR 16
Page 1 of 2 Pages.
INITIAL APPLICATION FOR
ASBESTOS TRAINING AGENCY CERTIFICATION
(Continued)
Name of Company
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 Asbestos 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.
8:60.
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 an asbestos training agency in New Jersey.
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-4
MAR 16
Page 2 of 2 Pages.
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