CEHS-12, employee qualifications, general ... - New Jersey



|New Jersey Department of Health |Indoor Environmental Consultant License Application |

|Consumer, Environmental and Occupational Health Service |Employee Qualifications: |

|Indoor Environments Program |GENERAL INDOOR ENVIRONMENTAL HEALTH ASSESSOR |

|PO Box 369 | |

|Trenton, NJ 08625-0369 | |

Directions for Completion:

(1) Type or legibly print all information. (2) Complete the page number and number of pages for this form on the bottom right corner of each page. (3) Please include all currently approved staff and staff that need to be removed or added to your list.

|Full Legal Name of Applicant (as it appears on the CEHS-9 Application form) |Reason for Submission |

|      |New Application Revision |

1. Applicants must employ at least one individual with at least one year of experience doing indoor air quality assessments.

2. Applicants must employ at least one individual who has at least one year of experience doing environmental consulting.

You must complete the information below for each individual who meets one or both of the qualifications:

|General Indoor Environmental Health Assessor Information |

|(Must include resume and notarized copy of permits/licenses and all certifications held.) |

|Check Type of Experience |Individual |Status of Staff |Date of |Number of Years|Type of Work Done |

|(Check both if applicable) |(Last Name, First Name, MI) | |Birth |of Experience | |

| | | | |** | |

|Indoor |Environmental | |New |Existing |Inactive | | | |

|Air Quality |Consulting | | | |* | | | |

|Assessments | | | | | | | | |

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CEHS-12

MAY 14 * No longer employed or active ** Attach resume. Page       of      

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