Form Hea 5122 PDF Details

Embarking on the process of obtaining or renewing an asbestos certification in Ohio requires familiarization with the appropriate regulatory paperwork, namely the HEA 5122 form issued by the Ohio Department of Health. This form serves as a comprehensive application for various certification categories within the realm of asbestos management, such as Asbestos Hazard Abatement Specialist, Air Monitoring Technician, Hazard Evaluation Specialist, Abatement Worker, and Project Designer. Applicants are obligated to provide detailed personal information, including social security number, date of birth, full name, and contact information, alongside proof of relevant training in the form of course certificates. Additionally, the form necessitates a clear, current color photograph of the applicant, submission fees tailored to the desired certification category, and addresses both for the applicant and, if different, the employer to which the certification letter and ID card should be sent. The provision of a social security number, mandated by the Ohio Revised Code and Administrative Code, underscores the form's role not only in certification but also in broader legal and regulatory frameworks, such as child support enforcement. The requirement for applicants to disclose any felony convictions related to environmental protection further highlights the seriousness with which the state of Ohio treats public health and safety matters concerning asbestos. Completing the application accurately is crucial, as the form emphasizes the legal affirmation by the applicant that all information provided is true and complete, underscoring the importance of integrity throughout the certification process.

QuestionAnswer
Form NameForm Hea 5122
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshea5122 asbestosodhohiogov form

Form Preview Example

Ohio Department of Health

Asbestos Certification Application

Ohio Administrative Code 3701-34

•One application, typed or printed legibly in ink, for each certification category.

•Attach a copy of your training course certificate(s).

•Need one clear, current and color photo of the applicant only by one of the following methods.

□Photo e-mailed to asbestos@odh.ohio.gov Name file with last name and last four digits of social security number (jones1234).

□Photo attached to application with applicant’s name written on the back of the photo.

•Check/money order, made payable to Treasurer, State of Ohio.

•Mail to: Ohio Department of Health, Accounts Receivable #2410, PO Box 15278, Columbus, OH 43215.

Application Type - Check only one

□ Initial □ Renewal – Certification #

Certification Category - Check only one

□ Asbestos Hazard Abatement Specialist

$200.00

□ Asbestos Hazard Abatement Air Monitoring Technician

$100.00

□ Asbestos Hazard Evaluation Specialist

$200.00

□ Asbestos Hazard Abatement Worker

$50.00

 

□ Asbestos Hazard Abatement Project Designer

$200.00

 

 

 

 

 

 

1.

Social Security Number

 

2. Date of Birth

 

 

3. Mail my certification letter and identification card to:

 

 

 

 

 

 

 

 

□ Applicant address

□ Employer address

4.

First Name

 

 

5. Middle Name

 

 

6. Last Name

 

 

 

 

 

 

 

 

 

 

 

 

7.

Home Address

 

 

 

8. City

 

9. State

 

10. Zip

 

 

 

 

 

 

 

 

 

 

11.

Home Phone

 

 

 

12. E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

Employer

 

 

 

 

14. Business Phone

 

15. Fax Number

 

 

 

 

 

 

 

 

 

 

16.

Employer Address

 

 

 

17. City

 

18. State

 

19. Zip

 

 

 

 

 

 

 

 

 

 

20.

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

List other state asbestos licenses or certificates you hold or have held.

 

 

 

 

 

 

 

 

 

 

 

 

22.

Have you ever been convicted of a felony under any state or federal law designated to protect the environment?

 

 

 

 

 

 

□ No

□ Yes If yes, attach a detailed explanation.

 

 

 

 

 

 

Provision of your social security number (SSN) is mandated by Ohio Revised Code 3123.50 and Ohio Administrative Code 3701-34.

Your SSN may be used for purposes including, but not limited to, identification of obligors under child support orders and verification of identity.

By signing below, I solemnly swear that the answers I have given on this application and all other information submitted, including training course certificate(s) and all appropriate attachments, whether provided in print, in writing or by other means, are accurate, complete and true to the best of my knowledge.

Applicant Signature

 

Date

 

 

 

 

 

 

 

 

For Office Use Only

Approved by & date

 

Denied by & date

Comments

 

 

 

 

 

 

 

 

HEA 5122 (REV 01/2011)

ID #

How to Edit Form Hea 5122 Online for Free

Form Hea 5122 can be completed online effortlessly. Just make use of FormsPal PDF editor to finish the job right away. The tool is consistently maintained by our team, getting cool functions and growing to be more convenient. Should you be seeking to begin, here's what it will require:

Step 1: Click the orange "Get Form" button above. It will open our editor so that you could begin filling in your form.

Step 2: As soon as you start the tool, you will find the document made ready to be filled out. Besides filling in different fields, you may as well do some other actions with the PDF, particularly adding any textual content, modifying the original text, inserting images, affixing your signature to the PDF, and more.

Pay close attention while filling in this form. Make certain each field is completed properly.

1. You need to complete the Form Hea 5122 properly, thus be mindful when working with the parts comprising these blank fields:

Filling in section 1 of Form Hea 5122

2. The next stage is usually to complete these particular fields: Employer Address, City, State, Zip, Email Address List other state, Have you ever been convicted of a, No Yes If yes attach a detailed, Provision of your social security, Applicant Signature, Date, For Office Use Only, Approved by date, Denied by date, and Comments HEA REV.

Stage # 2 in filling out Form Hea 5122

You can certainly make a mistake while completing your Date, for that reason make sure that you take a second look before you decide to send it in.

Step 3: Make sure your information is accurate and press "Done" to conclude the process. Get the Form Hea 5122 when you join for a 7-day free trial. Easily view the pdf within your FormsPal account, together with any edits and changes being automatically saved! Here at FormsPal.com, we strive to be sure that all your information is kept secure.

Form Hea 5122 isn’t the one you’re looking for?

Related Documents