Fillable Asbestos Abatement 150 Des Moines Street Des Moines, (Office of the Chief Information Officer)

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Asbestos Abatement 150 Des Moines Street Des Moines, (Office of the Chief Information Officer)

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Iowa Division of Labor
Asbestos Abatement
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-281-6175
Fax: 515-725-2427
asbestos@iwd.iowa.gov
asbestos.iowa.gov
FOR OFFICE USE ONLY
License #:
Expiration date:
Check #:
Date entered:
New Renewal Replacement Previous Asbestos License #:
Instructions: Applicants must include non-refundable license fees payable to the Iowa Division of Labor and copies of
training certificates. Email a head-and-shoulder picture of applicant to: asbestos@iwd.iowa.gov
. Applicants for worker and
contractor/supervisor license must also complete and return the original Respirator Protection and original notarized
Physician’s Certification forms.
Asbestos License Application
License Type (more than one may be requested):
Worker - $20.00 Inspector - $20.00 Contractor/Supervisor - $50.00
Project Designer - $50.00 Management Planner - $20.00 Replacement Card - $10.00
Full applicant name
Date of birth
Social security #
Address
State
Zip
Phone number
Email
Contact person if different than applicant
Phone number
Notice: The Iowa Division of Labor may deny this application, or revoke or suspend your license if you knowingly make a false or fraudulent
statement on this application or the attached documents. Criminal charges, forfeiture of your application fee, denial of future applications and a civil
penalty of up to $5,000.00 may also result from obtaining or attempting to obtain a license through deceptive or fraudulent means.
Iowa Code Chapters 252J and 272D require records of asbestos licenses to be maintained by social security number. If you withhold your social
security number, this application will be denied. Your social security number, name and address may be shared with other state agencies. If you are
behind in payments to other agencies, this or future applications may be denied. If you have a license it may be suspended or revoked.
Certification and Authorization: I hereby certify the information I am submitting is true and valid and I am at least 18 years of age. I hereby
authorize my physician to release to the Iowa Division of Labor information about the physical examination described in the attached Physician’s
Certification, if applicable.
Mail the license to my address above (do not complete the box below)
Mail the license to someone other than myself (compete the box below)
Applicant Signature Date
Permittee Acknowledgement
Company name
Your name
Title
Phone number
Address
City
State
Zip
The permittee agrees to promptly deliver the license to the licensee.
Authorized Signature Date
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
200-001
01.27.2020
Complete bottom portion ONLY if license is to be mailed to someone other than licensee
click to sign
signature
click to edit
Instructions
Return the original completed form with an application for contractor/supervisor or worker asbestos license to the
Iowa Division of Labor at the above address. The medical questionnaire from 29 CFR 1926.1101, Appendix D, is for the
use of the physician and is not to be returned to the Iowa Division of Labor. The accuracy of this certification may be
verified by the Iowa Division of Labor. Falsification of a physician’s signature or other attempts to fraudulently obtain
an asbestos license may result in criminal charges, denial of your application, forfeiture of your application fee, denial
of any future applications for asbestos licenses and a civil penalty of up to $5,000.00
STATE OF COUNTY OF
Signed and sworn to (or affirmed) before me on this day of , 20 ,by .
NOTARY PUBLIC in and for the State of
My commission expires
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
Iowa Division of Labor
Asbestos Abatement
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-281-6175
Fax: 515-725-2427
asbestos@iwd.iowa.gov
asbestos.iowa.gov
FOR OFFICE USE ONLY
Physician’s Certification
I certify that I have performed a physical examination of the above applicant on the date indicated. I have read the
mandatory OSHA guidelines for this physical in 29 CFR 1910.134 and 1926.1101 and the examination I conducted was in
accordance with the OSHA guidelines. I performed a physical examination of the applicant focused on the pulmonary and
gastrointestinal systems, including tests of forced vital capacity and forced expiratory volume at one second. I interpreted
and classified the applicant’s chest in accordance with 29 CFR 1926.1101, Appendix E. The applicant was informed of the
result of the examination and of any medical conditions which require further explanation or treatment. The applicant was
informed of the increased risk of lung cancer attributed to the combined effects of smoking and asbestos exposure. I have
determined that the applicant is capable of working while wearing a negative pressure respirator without restriction.
I CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
Physician’s Signature Date License Number Date of Exam
200-004
01.27.2020
Date Received:
Approved Denied
Applicant’s full name
Date of birth
Physician Information
Name
Clinic name
Address
City
State
Zip
Phone number
Fax number
(name of physician)
This form must be submitted with a contractor/supervisor or worker asbestos license application. Complete Part I and either Part
II or Part III. Send the original signed forms to the address above. A photocopy will not be accepted. The accuracy of this
document may be verified by the Iowa Division of Labor. Falsification of any part of this form may result in criminal charges,
denial of application, forfeiture of application fee, denial of future application and a civil penalty up to $5,000.00. Please print
legibly.
Part I
Iowa Division of Labor
Asbestos Abatement
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-281-6175
Fax: 515-725-2427
asbestos@iwd.iowa.gov
asbestos.iowa.gov
Applicant Information
Name
Date of birth
Phone number
Respirator Information
Respirator name
Respirator model number
Respirator type
Respirator size
FOR OFFICE USE ONLY
Instructions
Date Received:
Asbestos License #:
Approved Denied
Fit Tester Information
Name
Company
Phone number
Address
City
State
Zip
Fit test method used
I certify that the above applicant has been successfully fit tested and is able to wear the above respirator. I certify that I am
familiar with the OSHA procedures for fit tests found in 29 CFR 1926.1101, Appendix C, and followed those procedures while
performing this fit test. I certify that the information on this form is true and accurate to the best of my knowledge.
Fit Tester Signature Date
200-002
03.28.2017
Part II
Part III
In order to protect my health, I will wear a positive pressure respirator such as a powered air purifying respirator whenever I am
in a regulated area.
Applicant Signature Date
Respiratory Protection Form
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Asbestos Abatement 150 Des Moines Street Des Moines, (Office of the Chief Information Officer)

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Completed 20 July 2020

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