19 Staniford Street, 2nd Floor
Boston, MA 02114
Phone: 617-626-6960 Fax: 617-626-6965
www.mass.gov/dols
ASBESTOS ANALYTICAL SERVICE APPLICATION
(In accordance with the provisions of M.G.L. c. 149, § 6-6F ½ and 453 CMR 6.00)
FOR OFFICE USE ONLY Initial application Renewal application Duplicate application issue
License number ___________________________ Date___________________Reviewer_________________________________________
Please complete each section below by printing or typing the information, attaching all required documentation, and signing the application.
Section 1: Applicant information
Company Name____________________________________________________________________________________________________
Phone______________________________________________________________ Fax__________________________________________
Email address_____________________________________________________________________________________________________
Business Location (Street)____________________________________________________________________________________________
City/Town_________________________________________________State_______________________________ Zip__________________
Mailing address (if different)__________________________________________________________________________________________
City/Town_________________________________________________ State ______________________________ Zip_________________
Federal Identification Number_________________________________________________________________________________________
Section 2: Attachments to be submitted with the application:
1. (A) If applicant is a Sole Proprietorships or Partnership: A copy of the Business Certificate as filed in the City or
Town Clerk’s Office of the city or town where the applicant is located.
(B) If applicant is a Corporation or LLC:
Organized in MA in existence for less than one (1) year, provide a copy of the short form Certificate of Legal
Existence, issued by the Secretary of the Commonwealth’s Office.*
Organized in MA in existence for more than (1) year, provide a Certificate of Good Standing, issued by the
Secretary of the Commonwealth’s Office.*
Foreign Corporation (a corporation transacting business in the Commonwealth of MA and organized under
laws of a different state), provide a copy of the Foreign Corporation Certificate and a Certificate of Good
Standing issued by the Secretary of the Commonwealth’s Office.*
*Secretary of the Commonwealth’s Office: One Ashburton Place, Boston, MA 02108-1512; Tel.: 1-800-392-6090;
www.sec.state.ma.us/cor/coridx.htm. Do not send the Certificate of Good Standing issued by the Massachusetts
Department of Revenue.
(C) Not applicable. I am an Individual, Public Entity or Other, as noted in Section I above.
(D) If applicant receives samples by mail ONLY. Please include a letter stating that.
2. A list of all names, acronyms or other identifiers by which the applicant does or has done business, and the address(es)
and telephone number(s) of the business.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
3. The type(s) of approval/certification listed at 453 CMR 6.08(1)(a) through (d) for which the applicant is applying.
Class A Certificate Class B Certificate Class C Certificate Class D Certificate
4. If the applicant has employees, evidence that Asbestos Analytical Work to be performed by the applicant is covered under
a current workers' compensation policy or self-insurance program must be provided with the application. Certificate of