Fill and Sign the Collaborative Consulting Agreement Template 29969886 Form

New Jersey State Department of Health & Senior Services Consumer & Environmental Health Services P. O. Box 372, Trenton, NJ 08625-0372 For NJDHSS Use Only Transmittal No.: LTDate Received: (609) 631-6749 / / [ ] Check [ ] Mo. No.: LEAD TRAINING AGENCY CERTIFICATION Renewal Application Amount: Initials: Renewal applications must be submitted at least 180 calendar days prior to the expiration date of the discipline you wish to renew. Please type or pri nt legibly in ink. Only one course per application. Initial course and corresponding refresher course may be submitted on a single application. If you have any questions call the NJDHSS at the above number. Once you have completed this application, send it to the above address. I. APPLICATION FEE AND COURSE TYPE Course Fee: A non-refundable application fee for annual certification in the amount of $500.00 per discipline (note: initial and refresher courses are separate disciplines) must be forwarded wi th this application. The fee must be paid by certified check or money order and be made payable to the "New Jersey Department of Health & Senior Services". Course Discipline Type of Application RENEWAL (Make check in appropriate column. Check no more than one initial and one corresponding refresher) Initial Refresher Discipline Worker-Housing & Public Buildings Supervisor- Housing & Public Buildings Worker-Commercial Buildings & Superstructures Supervisor- Commercial Buildings & Supers tructures Inspector/Risk Assessor Planner/Project Designer II. GENERAL APPLICANT INFORMATION Name of Agency Business Telephone ( ) Mailing Address Agency Number Fax Number ( ) Federal Employer I.D. Number City State Is the street address of the agency different than above address? [ ] No [ ] Yes Street Address: City Zip Code If yes, the following must be completed: State Zip Code Web Address (if applicable) III. TRAINING MANAGER INFORMATION Name Posi tion and/or Title with Company: Address City Telephone ( State Zip Code E-mail Address (if applicable) ) IV. APPLICANT (AS IDENTIFIED IN SECTION II. ABOVE) INFORMATION Is all of the information contained in the previous application still accurate? [ ] No [ ] Yes (If you check “No” you must include any updated information or materials with this application.) If applicable, has any outstanding penalties been paid? [ ] No [ ] Yes (If you check “No” you must pay all penalties before your re-certification can be approved.) V. APPLICANT STATEMENT AND SIGNATURE The information contained in this "Lead Training Agency Certification Application" is accurate, true and complete to the best of my knowledge. I understand that if such information contained in this application is false, I am subject to the penalty provisions under N.J.A.C. 8:62. I understand that this application is subject to verification and that I agree to provide any additional documentation as required. For the same purpose I also understand that outside sources may be contacted and that I do hereby give permission for disclosure of any information which may be needed to determine certification application validity and/or eligibility. I also understand that failure to provide full disclosure of any of the requested or required information may result in rejection of this application for approval. I also understand that completion of this application does not guarantee certification as a lead training agency in New Jersey. I certify that this agency can operate in compliance with N.J.A.C. 8:62. I am authorized to sign for and in behalf of persons listed as owners, partners, shareholders, officers and directors of the company.. Name (Print): Title Signature Date Page 1 of 1