Asbestos Worker Application Form PDF Details

The Asbestos Worker Application form, as mandated by the State of Illinois and the Illinois Department of Public Health (IDPH), is a critical document for individuals seeking licensure to work with asbestos in various environments, including public and non-public school facilities (grades one through twelve), along with commercial and public buildings. This form outlines the necessary qualifications and steps required for licensure, emphasizing the need for applicants to be at least 18 years old, submit a non-refundable fee, and provide specific documentation such as a photograph, a completed child support statement, and proof of having completed an IDPH accredited initial training course or appropriate refresher courses if the initial certification has expired. Additionally, the form requires the disclosure of the applicant's social security number as part of the licensing process, in alignment with the Illinois Administrative Procedure Act. It also outlines the procedures for license expiration, renewal, reinstatement, and the issuance of duplicate licenses, stressing the importance of keeping training certificates current and the potential consequences of failing to do so. Applicants are informed of the necessity to authorize the release of their personal contact information for public distribution, highlighting the significance of understanding the implications of the Public Information Disclosure section. The completion and submission of this form, accompanied by the relevant fees and documentation, are vital steps in securing an asbestos worker license, contributing to the safety and regulation of asbestos abatement activities in Illinois.

QuestionAnswer
Form NameAsbestos Worker Application Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesshall idph licenses search, asbestos idph worker, license idph worker, application asbestos illinois

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State of Illinois

Illinois Department of Public Health

APPLICATION FOR ASBESTOS WORKER LICENSE

QUALIFICATIONS FOR ASBESTOS WORKER LICENSE

In accordance with the Asbestos Abatement Act and Code, and the Commercial and Public Building Asbestos Abatement Act (Public Act

89-143, effective July 14, 1995) the Illinois Department of Public Health (IDPH) shall license persons desiring to serve as asbestos workers in Illinois public and non-public school facilities (grades one through twelve), and commercial and public buildings. The IDPH asbestos worker license allows you to conduct asbestos worker activities in commercial and public buildings, as well as schools.

GENERAL LICENSING INFORMATION

All licenses shall expire on February 1 of each year. Licenses issued on October 31 or before will expire February 1of the coming year. Licenses issued on November 1 or after will expire February 1 of the following year. (EXAMPLE: Applicants whose licenses are issued on October 31 will be issued a license for 3 months. Applicants whose licenses are issued November 1 will be issued a license for 1 year and 3 months.)

To become an Illinois Department of Public Health licensed asbestos worker, the applicant shall:

1.Be at least 18 years of age.

2.Submit a completed and signed application including the child support statement (enclosed).

3.Submit a $25.00 check or money order made payable to the Illinois Department of Public Health. This fee is NOT REFUNDABLE.

4.Submit one 1" x 1" photograph of applicant (head and shoulders only) with the full name of the applicant on the back of the photograph. The photograph shall be an original, clear, current and color picture of the applicant. The license will not be issued without the identifying photograph.

5.Submit an IDPH accredited initial training course certificate for asbestos worker or contractor/supervisor. If the initial training course certificate has expired the applicant shall also include copies of IDPH accredited refresher training course certificates for each year indicating no lapse in training. The applicant shall complete the same type of refresher course as initial course.

6.In accordance with the requirements of the Illinois Administrative Procedure Act, 5 ILCS 100, the Department of Public Health requires the disclosure of your social security number as part of the license application. Failure to provide your social security number shall result in the denial of your license application.

Duplicate licenses are obtained by submitting a written request to the Department for a duplicate license with a photograph of the licensee and a $15.00 check or money order. A duplicate license will not be issued if the training course certificate is expired. Any changes in the licensee's name or address must be submitted in writing.

A refresher course shall be completed annually to maintain accreditation and licensure. If a training course certificate has been expired for more than one year from the expiration date, the applicant shall retake the initial course. It is the applicant's responsibility to keep their training course certificates current. The Department will verify all training course certificates, submitted for licensure, with the training course provider before a license is issued. It takes approximately fifteen working days to process a license.

Renewal of licenses - An applicant shall submit a current IDPH accredited refresher course certificate. All license renewals are due December 31 of each year. A $15.00 late fee will be required if the renewal application is received January 1 or after.

Reinstatement of licenses - An applicant whose license has been expired for more than one year may apply to the Department for reinstatement. The applicant shall meet the requirements of a new applicant and submit a reinstatement fee of $50.00 in addition to the $25.00 application fee.

Reciprocity - Out of state residents applying for licensure in Illinois for the first time, may submit U.S. EPA or other state accredited training course certificates and meet the requirements of a new applicant.

It is required by law (5 IlCS/100/10-65 (c) of the Illinois Administrative Procedure Act, amended by P.A. 87-823 that individual licensees certify whether they are more than 30 days delinquent in payment of child support. All applicants shall comply with this Act. Applicants shall complete and sign the child support statement. Failure to complete this statement will result in an incomplete application, and a delay in issuing the license. Making a false statement may place you in contempt of court.

The PUBLIC INFORMATION DISCLOSURE information must be completed to allow the Department to release your personal contact information for public distribution, through freedom of information (FOI) request, Internet listing, etc. ONLY those asbestos licensees who complete this information will be included in Department lists.

Failure to provide all of the requested information will result in delay of the license. Please submit all applications to the Illinois Department of Public Health, Asbestos Program, 525 West Jefferson Street, Springfield, Illinois 62761

If you have any questions, please contact the Asbestos Program at (217)782-3517, for the hearing impaired only (TTY# 800-547-0466).

Applications are published on the Internet at

WWW.IDPH.STATE.IL.US/ENVHEALTH/EHHOME.HTM

IL 482-0498 (Revised 01/04)

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State of Illinois

Illinois Department of Public Health

APPLICATION FOR ASBESTOS WORKER LICENSE

IlLLINOIS DEPARTMENT OF PUBLIC HEALTH

ID#

DIVISION OF ENVIRONMENTAL HEALTH

 

 

 

For IDPH Use Only

525 WEST JEFFERSON STREET

 

 

 

SPRINGFIELD, IL 62761

 

 

 

$25.00 CHECK OR MONEY ORDER MUST ACCOMPANY THIS APPLICATION

 

 

 

Please Type or Print

 

 

 

APPLICANT NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

 

 

 

Middle Initial

 

 

 

 

 

Last Name

HOME ADDRESS

 

 

 

 

 

 

 

 

 

 

 

COUNTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

STATE

 

 

ZIP CODE

 

 

 

 

 

HOME PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY#

 

 

 

APPLICANT'S AGE

 

 

 

 

 

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In Accordance with the requirements of the Illinois Administrative Procedure Act, 5 ILCS 100, the Department of Public Health requires the disclosure of your social security number as part of the license application. Failure to provide your social security number shall result in the denial of your license application.

A COPY OF AN IDPH ACCREDITED INITIAL TRAINING COURSE CERTIFICATE SHALL BE INCLUDED WITH THE APPLICATION

The law (5ILCS/100/10-65) requires that all applicants complete and sign the following statement. Failure to complete and sign this statement will result in an incomplete application and delay in issuing your license. Making a false statement may place you in contempt of court. Check only one box!

I am not more than 30 days delinquent in complying with a child support order; or

I am more than 30 days delinquent in complying with a child support order; or

This statement does not apply.

The Public Information Disclosure below must be completed to allow the Departmenbt to relase your personal contact information for public distribution, through freedom of information (FOI) request, Internet listing, etc. ONLY those asbestos licensees who complete this information will be inlcuded in the Department lists. By checking a box below, you authorize this Department to publish your business or personal information on all IDPH listings. Your signature further confirms your agreement to hold harmless and release this Department from any liability arising from release of the information authorized below. I authorize the Illinois Department of Public

Health to include my:

 

 

(Check only ONE box)

Personal Information

I do not wish to be listed

SUBMIT TWO 1" x 1" PHOTOGRAPHS OF THE APPLICANT (head and shoulders only).

I hereby certify that the information submitted is true and valid and I understand that the Illinois Department of Public Health may deny, revoke or suspend my application for an Asbestos Worker License for knowingly making false or fraudulent claims.

Signature Field

DATE

IMPORTANT NOTICE

THIS STATE AGENCY IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARYTO ACCOMPLISH THE STAUTORY PURPOSE AS OUTLINED UNDER PUBLIC ACT 83-1325. DISCLOSURE OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE ANY INFORMATION COULD RESULT IN DENIAL, REVOCATION OR SUSPENSION OF THE APPLICANTS LICENSE. THIS FORM HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.

IL 482-0498 (Revised 01/04)

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