Cn 1300 Form – Fill Out and Use This PDF

FIRST NAMEMIDDLE INITIAL LAST NAMEJR. SR. etc

4 - APPLICANT IDENTIFICATION INFORMATION (CONTINUED)

SOCIAL SECURITY NUMBER	DATE OF BIRTH	WEIGHT / POUNDS	HEIGHT / FEET INCHES		GENDER
						MALE		FEMALE

5 - EDUCATION / PROFESSIONAL DEGREES, DIPLOMAS, AND CERTIFICATES (attach supporting documentation when required)

	HIGHEST LEVEL	HIGH SCHOOL	GED	TECHNICAL	COLLEGE DEGREE	2 YR	4 YR	4 YR +
	COMPLETED	DIPLOMA

6 - EMPLOYMENT HISTORY (attach resume when required or attach additional sheet if needed)

7 - ASBESTOS TRAINING COURSE CERTIFICATE(S) (attach copies of course completion certificates)

FIRST TIME TENNESSEE APPLICANT:

INITIAL COURSE COMPLETION CERTIFICATE(S) FROM COMMISSIONER ACCREDITED TRAINING PROGRAM;

OR

REFRESHER COURSE COMPLETION CERTIFICATE(S) FROM A COMMISSIONER ACCREDITED TRAINING PROGRAM AND COURSE COMPLETION CERTIFICATE(S) FROM THE PREVIOUS YEAR FROM A RECOGNIZED TRAINING PROGRAM.

RE-ACCREDITATION APPLICANT:

REFRESHER COURSE COMPLETION CERTIFICATE(S) FROM A COMMISSIONER ACCREDITED TRAINING PROGRAM.

8 - ENVIRONMENTAL NON-COMPLIANCE ACTIONS (attach supporting documentation)

HAVE YOU EVER RECEIVED A VIOLATION? IF YES, LIST VIOLATION(S) (USE SEPARATE SHEET IF NEEDED)

STATE(S) WHERE OCCURRED

9 - CERTIFICATION AND SIGNATURE

I certify, under penalty of law, that: I am lawfully present in the United States as a U.S. citizen or a qualified alien as defined in 8 U.S.C. §1641(b); this document and all attachments were prepared by me or under my direction or supervision; and, all of the submitted information is, to the best of my knowledge and belief, true, accurate, and complete. I understand that the penalties for providing false information and making false or fraudulent statements or representations may include revocation of the permit, license or accreditation, civil penalties, and/or criminal prosecution resulting in a fine, imprisonment or both. As specified in Tennessee Code Annotated Section 39-16-702(a)(4), this declaration is made under penalty of perjury. I affirm that the work practice standards according to Chapter Rule 1200-01-20-.03 will be followed. I authorize the State of Tennessee to verify any information on or included with this application.

Applicant Signature

Printed Name

Date (mm / dd / yyyy)

As required under Chapter Rule 1200-01-20-.03, individuals shall have in their possession a valid Tennessee asbestos accreditation photo identifica- tion card that lists accredited discipline(s) with them at the work site. Individuals should be aware that training requirements under NESHAP and OSHA regulations may differ.

ALL APPLICANTS MUST SUBMIT:

1.A COMPLETED AND SIGNED APPLICATION - IN INK

2.CURRENT COURSE COMPLETION CERTIFICATE(S)

3.VALID DOCUMENTATION OF EDUCATION AND/OR WORK EXPERIENCE WHEN REQUIRED

4.2" x 2" COLOR PASSPORT PHOTO

5.APPROPRIATE FEES FOR EACH DISCIPLINE OR ATTACH COPY OF ONLINE PAYMENT RECEIPT WHEN APPLICABLE

6.A COMPLETED ELIGIBILITY VERIFICATION FOR ENTITLEMENTS ACT (EVEA) ATTESTATION FORM CN-1497 WITH VALID, LEGIBLE COPIES (FRONT AND BACK) OF IDENTIFICATION DOCUMENT(S) ATTACHED TO THE APPLICATION.

CN-1300 (Rev. 12 -16)

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INSTRUCTIONS AND CLARIFICATION "APPLICATION TO CONDUCT ASBESTOS ACTIVITIES - INDIVIDUAL"

Refer to Chapter Rule 1200-01-20 for complete accreditation requirements:

http://www.state.tn.us/sos/rules/1200/1200-01/1200-01-20.20090623.pdf

REQUIRED FOR ALL APPLICANTS:

1)Complete all sections of the application in ink including the education and work sections;

2)Complete and attach ELIGIBILITY VERIFICATION FOR ENTITLEMENTS ACT (EVEA) - Form CN-1497 and include legible copies (front and back) of valid identification documents (refer to "EVEA" Instructions);

3)Training Certificate(s) - First-time Tennessee applicant: From a Commissioner accredited training program, provide a current copy of an initial course completion certificate in the applied for discipline(s); OR refresher course completion certificate(s) from a Commissioner accredit- ed training program and refresher course completion certificate(s) from the previous year from a recognized training program.

Re-accreditation applicant: From a Commissioner accredited training program, provide a current copy of a refresher course completion certificate in the applied for discipline(s);

4)Documentation of education and/or work experience - First-time Tennessee applicant: Include copy of official academic transcripts or diploma as evidence of meeting the education requirements when applicable. Include resumes, letters of reference, or documentation of work experience as evidence of meeting the work experience requirements when applicable. Refer below to "INDIVIDUAL DISCIPLINE EDUCATION AND/OR WORK EXPERIENCE REQUIREMENTS" for additional guidance. Re-accreditation applicant: Complete all sections of the application including the education and work sections. Education and/or work experience documents are not required if applying for re-accreditation in the same discipline(s) within 60 days prior to or 30 days after the expiration date of the current accreditation;

5)Include a 2" x 2" color passport photo;

6)Include the appropriate fees for each discipline or attach a copy of the online payment receipt.

INDIVIDUAL DISCIPLINE EDUCATION AND/OR WORK REQUIREMENTS: (Attach supporting documentation to application.)

WORKER: A formal education and work experience are not required for this discipline. Complete all sections of the application including the education and work sections.

SUPERVISOR: A formal education is not required for this discipline. Must have one year experience as an accredited asbestos worker or have two years of experience in a related field (e.g., environmental remediation work, asbestos, lead) or in the building construction trades. Complete all sections of the application including the education and work sections.

PROJECT MONITOR: Currently hold credentials as a registered architect, certified industrial hygienist, licensed professional engineer and/or certification in a related engineering/health/environmental field (e.g., safety professional, environmental scientist); or a bachelor's de- gree and one year experience in a related field (e.g., asbestos, lead, environmental remediation work, or building construction); or an associ- ate's degree and two years experience in a related field (e.g., asbestos, lead, environmental remediation work, or building construction); or a high school diploma and four years experience in a related field (e.g., environmental remediation work, asbestos, lead) or in the building con- struction trades.

INSPECTOR: Have a high school diploma or the equivalent. Work experience not required for this discipline. Complete all sections of the application.

MANAGEMENT PLANNER: Currently hold credentials as a registered architect, certified industrial hygienist, licensed professional engi- neer and/or certification in a related engineering/health/environmental field (e.g., safety professional, environmental scientist); or a bachelor's degree and one year experience in a related field (e.g., asbestos, lead, or environmental remediation work or building construction); or an associate's degree and two years experience in a related field (e.g., asbestos, lead, or environmental remediation work or building construc- tion); or a high school diploma and four years experience in a related field (e.g., environmental remediation work, asbestos, lead) or in the building construction trades.

*First-time Tennessee applicant for Management Planner: From a Commissioner accredited training program, must also provide a current copy of an initial course completion certificate in the inspector discipline; OR from a Commissioner accredited training program, must provide a current copy of a refresher course completion certificate in the inspector discipline; and from an accredited training program, must also provide a copy of a course completion certificate from the previous year in the inspector discipline.

*Re-accreditation Management Planner applicant: From a Commissioner accredited asbestos training program, must provide a current copy of a refresher course completion certificate in the inspector discipline.

PROJECT DESIGNER: Currently hold credentials as a registered architect, certified industrial hygienist, licensed professional engineer and/or certification in a related engineering/health/environmental field (e.g., safety professional, environmental scientist); or a bachelor's de- gree and one year experience in a related field (e.g., asbestos, lead, environmental remediation work, or building construction); or an associ- ate's degree and two years experience in a related field (e.g., asbestos, lead, environmental remediation work, or building construction.

IMPORTANT INFORMATION:

When an applicant receives their Tennessee asbestos accreditation card, the application process is complete pursuant to Rule 1200-01-20, and the Individual may then conduct asbestos activities under the accredited discipline(s).

Accredited individuals are required to have their Tennessee asbestos accreditation card with them at the work site at all times.

Individuals should be aware that training requirements under the NESHAP and OSHA regulations may differ.

Local Education Agency (LEA) employees who receive accreditation with an LEA fee exemption can only use their credentials to conduct asbestos activities for the specific LEA named on the application.

CN-1300 (Rev. 12 -16)

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RDA 3078