Cn 1300 Form PDF Details

Embarking on asbestos activities in Tennessee requires a thorough understanding of the CN 1300 form, a pivotal document issued by the State of Tennessee Department of Environment and Conservation. This form serves as an application for individuals seeking accreditation to conduct various asbestos-related tasks, underscoring the state's commitment to environmental safety and public health. Applicants are obliged to fill out the form meticulously, ensuring all sections are completed in ink, accompanied by necessary documentation such as the FORM CN-1497 for eligibility verification, proof of completed initial or refresher asbestos training courses, educational qualifications, work experience details, and a passport-size photo. The form also mandates the inclusion of fees for each discipline applied for, with clear instructions on the non-refundable nature of these fees and the online payment option for re-accreditation applicants. The procedures outlined not only facilitate a structured application process but also emphasize the importance of verifiable credentials in maintaining high standards in the management of asbestos, thereby protecting both workers and the wider community from potential hazards.

QuestionAnswer
Form NameCn 1300 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesremediation, ASHARA, swm, RDA

Form Preview Example

STATE OF TENNESSEE

DEPARTMENT OF ENVIRONMENT AND CONSERVATION

DIVISION OF SOLID WASTE MANAGEMENT—TOXIC SUBSTANCES PROGRAM WILLIAM R. SNODGRASS TENNESSEE TOWER

312 ROSA L. PARKS AVENUE, 14TH FLOOR NASHVILLE, TN 37243

APPLICATION TO CONDUCT ASBESTOS ACTIVITIES - INDIVIDUAL

FORM CN-1497

DOCS SUBMITTED

MEETS STANDARD

INSTRUCTIONS: Complete all sections of the application - in ink. Include all required supporting documentation. Make payments to Treasur-

er, State of Tennessee by check, money order, or cashier's check- do not send cash. Mail application, documentation, and payment to: State of Tennessee, Department of Environment and Conservation, Division of Fiscal Services - Fee Section, William R. Snodgrass Tennes- see Tower, 312 Rosa L. Parks Ave., 10th Floor, Nashville, TN 37243. Note: Re-accreditation applicants may pay invoice fee(s) online through TDEC Online Services Portal then mail the application, supporting documents, and a copy of the online-payment receipt directly to the address above.

Required Documentation: All applicants are required to provide (1) A signed FORM CN-1497 ELIGIBILITY VERIFICATION FOR ENTITLEMENTS

ACT (EVEA) with valid copies of identification documents (refer to "EVEA” INSTRUCTIONS); (2) A copy of a current, initial course completion certificate(s) (refer to "INSTRUCTIONS AND CLARIFICATION SHEET" for the complete training certificate requirements); (3) Valid documentation (diploma, certificate, or the equivalent) of education and/or work experience (refer to "INSTRUCTIONS AND CLARIFICATION SHEET" for the requirements for each discipline); and (4) A 2" x 2" color passport photo.

Pursuant to Rule 1200-01-02-.03(2)(e), it is specified that an accreditation card be issued within 60 working days after an application has been deemed complete. Applicants will be notified of incomplete applications and will have 15 days from the date of notification to complete the application. If an applicant fails to complete the application within 15 days, the application process will be cancelled, the applicant notified of the denial, and the applicant will be required to reapply. The application fee is non-refundable.

1 - APPLICANT INFORMATION

FIRST NAME

 

 

 

 

 

 

 

 

MIDDLE INITIAL

LAST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JR. SR. etc

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME PHONE NUMBER

 

CELL PHONE NUMBER

 

 

FAX NUMBER

 

 

 

 

EMAIL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

STATE

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS IF DIFFERENT FROM ABOVE

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

STATE

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2 - DISCIPLINE(S) AND FEE(S)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECK ALL THAT APPLY

WORKER

SUPERVISOR

 

PROJECT

INSPECTOR

MANAGEMENT

 

PROJECT

 

FEE SUBTOTAL

MONITOR

 

PLANNER

DESIGNER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INITIAL TN ACCREDITATION

 

 

 

 

 

$25

 

 

 

 

$125

 

 

 

 

$75

 

 

 

 

$125

 

 

 

$200

 

 

 

 

$150

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RE-ACCREDITATION

 

 

 

 

$25

 

 

 

$125

 

 

 

 

 

$75

 

 

 

$125

 

 

 

 

$200

 

 

 

$150

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOST CARD REPLACEMENT

 

 

 

$25

 

IF INVOICE IS PAID ONLINE, ENTER PAYMENT CONFIRMATION NUMBER(s)

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEA CHECK IF YOU ARE APPLYING AS A LOCAL EDUCATION AGENCY EMPLOYEE -

 

FEE TOTAL

 

$

 

 

 

 

 

 

 

 

 

 

ENTER $0 IN FEE TOTAL. PROVIDE LEA AGENCY INFORMATION BELOW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEA AGENCY NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF CONTACT PERSON

 

 

 

 

 

AREA CODE & PHONE No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 - DECLARATION OF CITIZENSHIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. CITIZEN

 

 

 

 

 

QUALIFIED ALIEN LAWFULLY PRESENT IN THE U.S.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALL APPLICANTS MUST COMPLETE AND ATTACH THE ELIGIBILITY VERIFICATION FOR ENTITLEMENTS ACT (EVEA) ATTESTATION FORM CN-1497 WITH LEGIBLE COPIES (FRONT AND BACK) OF VALID IDENTIFICATION DOCUMENT(S) ATTACHED.

WARNING: "YOUR STATEMENT IS MADE UNDER OATH OR AFFIRMATION. PROVIDING FALSE OR INCOMPLETE INFORMATION ARE GROUNDS FOR REJECTION OF APPLICATION OR REVOCATION OF ANY LICENSE, REGISTRATION, OR CERTIFICATION IF ISSUED. FALSE STATEMENTS OR INCOMPLETE INFORMATION ARE ALSO SUBJECT TO THE PENALTIES OF PERJURY UNDER TENNESSEE LAW."

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FD121416P

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

 

 

 

 

 

 

YEAR GRADUATED

SCHOOL NAME

DEGREE / CERTIFICATE

CERTIFICATE REGISTRATION NUMBER STATE ISSUED

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

FROM / TO

BUSINESS NAME - AREA CODE / PHONE NUMBER

DUTIES

SUPERVISOR

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.

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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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1. Before anything else, once completing the ASHARA, begin with the form section that has the subsequent blank fields:

Completing part 1 of tennessee asbestos license

2. Given that the previous section is finished, you need to include the essential details in LEA AGENCY NAME, NAME OF CONTACT PERSON, AREA CODE PHONE No, DECLARATION OF CITIZENSHIP, US CITIZEN, QUALIFIED ALIEN LAWFULLY PRESENT, ALL APPLICANTS MUST COMPLETE AND, PAGE OF, F D P, and RDA in order to move on further.

Filling out segment 2 in tennessee asbestos license

3. This next section is all about FIRST NAME, MIDDLE INITIAL LAST NAME, JR SR etc, APPLICANT IDENTIFICATION, DATE OF BIRTH, WEIGHT POUNDS, HEIGHT FEET INCHES, GENDER, MALE, FEMALE, EDUCATION PROFESSIONAL DEGREES, DEGREE CERTIFICATE CERTIFICATE, HIGH SCHOOL DIPLOMA, COLLEGE DEGREE, and GED - fill in each one of these fields.

MIDDLE INITIAL LAST NAME, WEIGHT  POUNDS, and COLLEGE DEGREE in tennessee asbestos license

4. This next section requires some additional information. Ensure you complete all the necessary fields - REFRESHER COURSE COMPLETION, REACCREDITATION APPLICANT, REFRESHER COURSE COMPLETION, ENVIRONMENTAL NONCOMPLIANCE, STATES WHERE OCCURRED, CERTIFICATION AND SIGNATURE I, Applicant Signature, Printed Name, and Date mm dd yyyy - to proceed further in your process!

Stage no. 4 of completing tennessee asbestos license

As to Date mm dd yyyy and ENVIRONMENTAL NONCOMPLIANCE, make sure you double-check them in this current part. Both of these are the key ones in this page.

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