Form SFN16610 "Asbestos Certification Application" - North Dakota

What Is Form SFN16610?

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

Form Details:

  • Released on February 1, 2011;
  • The latest edition provided by the North Dakota Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SFN16610 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN16610 "Asbestos Certification Application" - North Dakota

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ASBESTOS CERTIFICATION APPLICATION
North Dakota Department of Health
Asbestos Control Program
SFN 16610 (02/11)
GENERAL REQUIREMENTS
The following items must accompany this application:
1. An unaltered copy of the applicant’s original training certificate
received after successful completion of an AHERA-accredited training
OFFICE USE ONLY
course. Include all refresher certificates for initial certifications or if
Do not write in this space
your certification has been expired for more than three years.
2. A check or money order payable to the North Dakota Department of
Check Number ____________
Health in the amount of $50 per discipline. The $50 fee is waived for
Check Amount ____________
public employees.
Date Approved ____________
3. Send the application to:
Certificate
Number
____________
North Dakota Department of Health
nd
Division of Air Quality, 2
Floor
918 East Divide Avenue
Public Employee
Yes
No
Bismarck, ND 58501-1947
File Folder
Yes
No
Phone: (701) 328-5188
Fax:
(701) 328-5185
Name (Last, First, Middle)
Home Street Address
City
State
Zip
Home Telephone Number
Date of Birth (Month/Day/Year)
Social Security Number
Employer
Employer Address
City
State
Zip
Employer Telephone Number
Are you a citizen of the Unites States of America?
Yes
No
If no, what is your Alien Registration Number?
Have you ever been certified in North Dakota before?
Yes, Cert. Number________
No
Check the discipline(s) for which you are applying certification.
1.
Asbestos Abatement Worker
Initial
Recertification
2.
Asbestos Abatement Supervisor
Initial
Recertification
3.
Asbestos Inspector
Initial
Recertification
4.
Asbestos Management Planner
Initial
Recertification
5.
Asbestos Abatement Project Designer
Initial
Recertification
6.
Asbestos Abatement Project Monitor
Initial
Recertification
*In North Dakota as a project Monitor, you must also be certified as an Asbestos Abatement Supervisor or an Asbestos Abatement Project
Designer. You must include a copy of your NIOSH 582 or equivalent course certificate with your initial application.
I certify that the information included with this application is true and accurate.
___________________________________________________
Signature
Date
ASBESTOS CERTIFICATION APPLICATION
North Dakota Department of Health
Asbestos Control Program
SFN 16610 (02/11)
GENERAL REQUIREMENTS
The following items must accompany this application:
1. An unaltered copy of the applicant’s original training certificate
received after successful completion of an AHERA-accredited training
OFFICE USE ONLY
course. Include all refresher certificates for initial certifications or if
Do not write in this space
your certification has been expired for more than three years.
2. A check or money order payable to the North Dakota Department of
Check Number ____________
Health in the amount of $50 per discipline. The $50 fee is waived for
Check Amount ____________
public employees.
Date Approved ____________
3. Send the application to:
Certificate
Number
____________
North Dakota Department of Health
nd
Division of Air Quality, 2
Floor
918 East Divide Avenue
Public Employee
Yes
No
Bismarck, ND 58501-1947
File Folder
Yes
No
Phone: (701) 328-5188
Fax:
(701) 328-5185
Name (Last, First, Middle)
Home Street Address
City
State
Zip
Home Telephone Number
Date of Birth (Month/Day/Year)
Social Security Number
Employer
Employer Address
City
State
Zip
Employer Telephone Number
Are you a citizen of the Unites States of America?
Yes
No
If no, what is your Alien Registration Number?
Have you ever been certified in North Dakota before?
Yes, Cert. Number________
No
Check the discipline(s) for which you are applying certification.
1.
Asbestos Abatement Worker
Initial
Recertification
2.
Asbestos Abatement Supervisor
Initial
Recertification
3.
Asbestos Inspector
Initial
Recertification
4.
Asbestos Management Planner
Initial
Recertification
5.
Asbestos Abatement Project Designer
Initial
Recertification
6.
Asbestos Abatement Project Monitor
Initial
Recertification
*In North Dakota as a project Monitor, you must also be certified as an Asbestos Abatement Supervisor or an Asbestos Abatement Project
Designer. You must include a copy of your NIOSH 582 or equivalent course certificate with your initial application.
I certify that the information included with this application is true and accurate.
___________________________________________________
Signature
Date