150 Des Moines Street
Des Moines, IA 50309-1836
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: firstname.lastname@example.org
. 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
Contact person if different than applicant
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)
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.
Complete bottom portion ONLY if license is to be mailed to someone other than licensee
click to sign
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