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Instructions for Completing “Application for Lead Permit - Worker-Housing and Public Buildings” (A) Please read the following directions carefully before completing and submitting the application. Failure to follow these directions could result in denial of your application for a permit. General „Application must be typewritten or neatly and legibly printed in ink. „Fully complete the entire application, sign and date the application, and mail it to the address indicated at the top of the application. Application Fee, Type and Discipline „Fee: Must include a certified check or money order (no personal checks or cash) for $80 made payable to “New Jersey Department of Health and Senior Services” „Initial: If you have never had a New Jersey perm it (for this discipline) or you had a permit (for this discipline) and it has expired more than 90 days ago. „Renewal: If you have a New Jersey permit (for this discipline) and your permit has either not expired or has not been expired for more than 90 days. „Reciprocity: Do not use this application for reciprocity applications . Call 609-631-6749 for this application or go to www.state.nj.us/health/eoh/tsrp for the correct application. Social Security Number „Pursuant to the Privacy Act, 5 U.S.C. 552a, the disclosure of social security numbers is voluntary. „The use of social security numbers is for statistical purposes only. Telephone Numbers and E-mail address „During the review process, it is often necessary to contact the applicant regarding questions on their application. It is necessary that you provide a means by which we can contact you regarding your application. Applicant’s History of Legal Actions „If you check “yes” to any of these items you must provide a detailed explanation to fully explain the circumstances. Attachments All applications must include the following: „Certified Check or money order in the amount indicated on the application T No cash or personal checks will be T Must be made payable to the “New Jersey Department of Health and Senior Services”. T Application fees are non-refundable T No liability shall be assumed by the Department for the loss or delay in transmission of the application fee. „Passport-size color photograph of yourself (see approximate size at right) TMust be recent TFront face TFull face (at least ¾” wide) TNo hat TNo glasses TNo other item which would disguise overall features TWhite background, without clutter TClear TName and ID number (from permit) or control number (on EHS-9 form) must be printed on back of photo „Photocopy of the training certificate you received from your New Jersey certified training provider, demonstrating that you have successfully completed initial or refresher training (as appropriate). Other Attachments „Initial applicants - Must submit a completed application within one year of completing their training. If training is more than one year old, applicants must take entire initial training course and pass the examination again. „Renewal applicants - Must submit a completed application within the 90 calendar day period prior to or the 90 calendar day period after their previous permit expires. If a permit has been expired for more than 90 days the applicant must retake the entire initial training and pass the examination to be eligible for a permit. Note to ALL applicants: Applications which are pending for more than one year will be rejected. Applications will be returned which have not included the correct application fee or contain no proof of the appropriate training. Page 1 of 2 New Jersey State Department of Health & Senior Services Consumer and Environmental Health Services P. O. Box 372, Trenton, NJ 08625-0372 (609) 631-6749 FOR NJDHSS USE ONLY Transmittal No.: LT- Date Received: / [ ] Check [ ] MO Amount: $ A / Number: Initials: Application for Lead Permit Worker-Housing and Public Buildings Please type or print legibly in ink. Mail the original application, education and experience documents (see directions), passport photo (see directions), and a certified check or money order (personal checks and cash will not be accepted) to the above address. Checks should be made payable to the “New Jersey Department of Health and Senior Services” (the application fee is non-refundable). Initial applicants must submit a completed application within one year of completing their training. Renewal applicants must submit their application during the 90 calendar day period prior to or the 90 calendar day period after your previous permit’s expiration. Any applications pending in excess of one year will be rejected. If you have any questions, call the NJDHSS at the above number. I. Application Fee, Type and Discipline Fee: $80.00 Application Type: [ ] A. Initial [ ] B. Renewal Discipline: Date(s) of Most Recent Worker-Housing & Public Bldgs. Training: : A. Worker-Housing and Public Buildings Training Agency: II. General Applicant Information Last Name First Name MI ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Home Telephone Number ( ) Street Address City Social Security Number (see instructions) State Zip Code Date of Birth Sex ________/________/________ [ ] Male [ ] Female Name of Current Employer Address of Current Employer Daytime Telephone Number ( ) E-mail Address (if you have one) Employer Telephone ( ) Race (check one) [ ] 1. White, Non-Hispanic [ ] 2. Black, Non-Hispanic [ ] 3. Hispanic/Latino [ ] 4. Portuguese [ ] 5. Asian/Pacific Islander [ ] 6. Am. Indian/Alaskan Native [ ] 7. Other, specify:____________________________ Highest Level of Education (check one) [ ] A. Some High School [ ] C. Vocational/Technical School [ ] E. Associates Degree [ ] G. Masters Degree [ ] B. High School or Equivalent [ ] D. Some College [ ] F. Bachelors Degree [ ] H. Doctorate Height Weight Are there any children 6 years or younger in your household? [ ] No [ ] Yes _____ Feet _______ Inches ________ Pounds If Yes: There are _________ children 6 years or younger. Has applicant's name changed within the past 2 years? [ ] No [ ] Yes If yes, former name:____________________________ III. Applicant's History of Legal Actions If you answer "yes" to any of the following questions, you must provide a detailed statement to fully explain the circumstances and attach statement to this application. Has/is the applicant, identified in Section II above: Been subject to, or has pending, any disciplinary action(s), suspensions, or citation(s) of violation(s) by any [ ] Yes [ ] No administrative, governmental or regulatory agency, including, but not limited to, OSHA, EPA, NJDOL, NJDEP, NJDCA and NJDHSS? Now or has been subject to any order resulting from any criminal, civil or administrative proceedings brought against such company, persons or parties by any administrative, governmental or regulatory agency? [ ] Yes [ ] No IV. Applicant Statement and Signature The information contained in this "Application For Lead Permit" 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 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 understand that failure to provide full disclosure of any of the requested or required information may result in rejection of this application. I understand that completion of this application does not guarantee certification to conduct lead-based paint activities in New Jersey. Signature Date Page 2 of 2