Download Individual Asbestos Certification Application (PDF: 170KB/ 2 pages)

HOW TO APPLY
INDIVIDUAL ASBESTOS CERTIFICATION APPLICATION
A. Fill in this form with black or blue ink only. A separate form must be submitted for each certification. Allow 2-4
weeks for processing.
B. Include a passport quality photographic image of yourself.
C. Include a business check, cashier's check or money order made payable to the Minnesota Department of Health
(MDH). No cash or personal checks accepted. A service fee is charged for returned checks.
1. Fees are nonrefundable
a. $100 for Inspector, Management Planner or Project Designer certification
b. $50 for Worker or Supervisor certification
c. $25 for a duplicate certification
D. Out-of-state applicants must also include
1. a copy of the applicant's original initial training course diploma or a copy of the current asbestos certification
from the state that the applicant is certified in; and
2. a copy of the applicant's original diploma from the most current Minnesota asbestos refresher training course.
E. Mail to
Minnesota Department of Health
Asbestos/Lead Compliance Unit
PO Box 64497
St Paul, MN 55164-0497
Questions? Call 651-201-4620 or visit the MDH website (www.health.state.mn.us/asbestos).
CERTIFICATION INFORMATION
1. Check one of the following application types
Initial Certification
2. Check one of the following certifications
Worker
Supervisor
Renewal Certification
Inspector
Duplicate Certification
Project Designer
Management Planner
APPLICANT’S INFORMATION
3. Name
Last
4. Social Security #
First
-
-
Middle Initial
5. Date of Birth
/
Required by MN Statutes, §270C.72
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mm/dd/yyyy
6. Street Address
7. City
8. State
9. Zip
10. County
11. Phone # (
)-
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12. Training Course Diploma Number
13. Training Course Start Date
/
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mm/dd/yyyy
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14. Applies only to initial certification for worker, supervisor, inspector, project designer or management planner.
Check one of the items in the appropriate discipline section below
Worker certification (Check one)
2 years full-time attendance, or part-time equivalent, in a general construction trades apprenticeship program; or
2 years of postsecondary education in construction management, industrial hygiene or technology safety, or physical
or life science, and completed an OSHA 510 Occupational Safety & Health Standards for construction course; or
18 months in a vocational training program in a general construction trade; or
1,000 hours work experience in general construction trades.
Supervisor certification (Check one)
2,000 hours work experience in asbestos-related work, safety, industrial hygiene, hazardous materials control, or
other general construction trades; or
500 hours work experience in asbestos-related work, safety, industrial hygiene, hazardous materials control, or
general construction trades AND a bachelor’s degree in architecture, engineering, physical or life science; or
a master’s degree in environmental health, industrial hygiene, or safety; or
completion of a general construction trades apprenticeship program.
Inspector certification (Check one)
500 hours work experience in the field of building inspection, asbestos-related work, safety, industrial hygiene, or
hazardous materials control; or
completion of a general construction trades apprenticeship program; or
licensure as a Minnesota building official; or
a bachelor's degree in architecture, engineering, industrial hygiene or technology safety, or physical or life science,
AND 40 hours of on-site asbestos inspection experience accompanying a Minnesota-certified asbestos inspector; or
credentialing as a registered architect, licensed professional engineer, certified industrial hygienist, or certified safety
professional.
Project Designer certification (Check one)
4,000 hours work experience in asbestos-related work or asbestos management activity; or
credentialing as a registered architect, licensed professional engineer, or certified safety professional.
Management Planner certification (Check one)
1,000 hours work experience in building inspection, asbestos-related work, safety, industrial hygiene, or hazardous
materials control; or
500 hours work experience in building inspection, asbestos-related work, safety, industrial hygiene or hazardous
material control AND a bachelor's degree in architecture, engineering, industrial hygiene or technology safety, or
physical or life science; or
250 hours work experience in building inspection, asbestos-related work, safety, industrial hygiene or hazardous
material control AND a master’s degree in environmental health, industrial hygiene, or safety; or
licensure as a Minnesota building official; or
credentialing as a registered architect, licensed professional engineer, or certified industrial hygienist or safety
professional.
SIGNATURE
I have provided true and complete information and I understand MDH’s Tennessen Warning which is available by calling
651-201-4620 or from MDH's website (www.health.state.mn.us/divs/eh/asbestos/forms/comtenwarn.pdf). I also
understand that submitting false information allows MDH to deny, suspend, revoke or take other action against this
certification.
Signature
Date
/
mm/dd/yyyy
/
To obtain a copy of this document in an accessible format (electronic ASCII text, Braille, large print, or audio) please call
651-201-4620.
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