Application for Lead Certification

Individual/ Company Name:	___________________________________________________________________

Complete Mailing Address:	___________________________________________________________________

___________________________________________________________________________________________________

Social Security Number: ____-___-______ Federal EI#: _________________ Date of Birth: ___/____/____
							                         (if applicable)

Phone #:  ____________________ Fax #:  ____________________  Mobile/Beeper #:  ____________________


Check the type of certification(s) for which you are applying:

_____	Individual

_____	Contractor/Firm

_____	Training Provider

_____	Re-certification


Contractor/Firm

Lead-Based Paint Activities……$50.00


Individual 

Inspector……………..$50.00
Risk Assessor…………50.00
Supervisor…………….50.00
Project Designer………50.00
Abatement Worker……25.00


Training Provider

Inspector……………..$200.00
Risk Assessor…………200.00
Supervisor…………….200.00
Project Designer………200.00
Abatement Worker……200.00

Payment in full must be sent along with Application and required materials.  

Please make check or money order payable to "State of Delaware".  Application fees are non-refundable.


Signature  __________________________________________	Date  ___________________

This Application is in compliance with and subject to the provisions of the State of Delaware 
Regulations Governing Lead-Based Paint Hazards, adopted July 15, 1998, by the Secretary of 
Delaware Health & Social Services, under the authority of 16 DE Code, Chapter 1, §122(3)(t); 
Date of Effect August 11, 1998.


OFFICE USE ONLY

Certificate #
Issue Date
Effective Date
Expiration Date



Authorized Signature / Date

Supervisor Initial
Total Fee(s)



OFFICE OF LEAD POISONING PREVENTION
HEALTH SYSTEMS PROTECTION
417 Federal Street
Dover, DE 19901

Phone: (302) 744-4546     Contact: Russell R. Dynes
Document #35-05-20/7/10/05